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VOL.79 NO.8 November 2006 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Extraordinary Medicine


CONTENTS SAN FRANCISCO MEDICINE September 2006 Volume 79, Number 8 Extraordinary Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 Nanotechnology and Medicine David W. Stretavan, MD

4 On Your Behalf 6 Upcoming SFMS Events

12 New and Old Approaches to Healing Frederick Hecht, MD 13 Expanding Life Michael Lerner, PhD

7 President’s Message Gordon Fung, MD, MPH 9 Editorial Mike Denney, MD, PhD

14 Brachytherapy for Prostate Cancer Mack Roach III, MD; I-Chow Hsu, MD; Alex Gottschalk, MD, PhD; Joyce Speight, MD, PhD; and Katsuto Shinohara, MD

31 Hospital News 33 Classified Ads

16 Marijuana for HIV-Related Conditions Donald Abrams, MD

34 In Memoriam Nancy Thomson, MD

18 Pancreas Transplantation Peter Stock, MD Editorial and Advertising Offices

20 The Art of Healing: Q&A with Rachel Naomi Remen Katie Kelly 22 Revisiting Hallucinogen Research Charles S. Grob, MD 24 Teenager Refuses Treatment Stephen J. Askin, MD, and Rebecca L. Cachia-Riedl 26 The Healing Power of Sound Simon Heather, MBACC, MCOH

1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon request. Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605

How Does This Issue of SFM Look? We are trying a few new things at San Francisco Medicine Magazine and would appreciate your feedback. If you have any comments on the look, style, or printing quality of this issue, please let us know! All comments should be directed to Amanda Denz, our managing editor, by calling (415) 561-0850 extension 261 or sending an e-mail to adenz@sfms.org.

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november 2006 San Francisco Medicine 


ON YOUR BEHALF

November 2006 Volume 79, Number 8

A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay

Notes from the Membership Department

Cover Artist Amanda Denz

Time is Running out for the SFMS Night at the Symphony

Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin Judith Mates

Leo van der Reis

Wade Aubry

Ricki Pollycove Jerome Fishgold

Toni Brayer

Jordan Shlain

Corey Maas

Leonard Shlain Gretchen Gooding

Erica Goode

David Smith

Samuel Kao

Stephen Walsh Kathleen Unger

Thomas Lee

Arthur Lyons

Alan Greenwald Rita Melkonian Kenneth Maybury

SFMS Officers President Gordon L. Fung President-Elect Stephen E. Follansbee Secretary Charles J. Wibbelsman Treasurer Stephen H. Fugaro

Seats are limited, and they’re going fast for the SFMS Night at the San Francisco Symphony on Thursday, November 30th! Enjoy a preconcert reception in the Davies Symphony Hall Green Room with hors d’oeuvres and beverages, followed by a vibrant program of Rachmaninoff and Tchaikovsky conducted by Vladimir Ashkenazy. Orchestra seats are $77.00, first tier are $67.00. The deadline to order tickets is Wednesday, November 8! For more information, or to order tickets, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Editor Mike Denney Immediate Past President Alan Greenwald

Something New and Fun Coming Soon!

SFMS Executive Staff

Mark your calendars for Thursday, January 18, 2007 for the SFMS Tennis Mixer at the San Francisco Tennis Club. This event will be a fun and relaxing introduction to the courts and amenities of this top-notch club, followed by a margarita mixer with light appetizers. More information available soon. The Membership Department and the physician members of the Membership Committee are actively exploring future events and services to benefit SFMS members. Suggestions for events and proposed membership benefits from the membership are greatly appreciated. Please feel free to contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Executive Director Mary Lou Licwinko Director of Public Health & Education Steve L. Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Board of Directors Mei-Ling E. Fong

John W. Pierce

Thomas H. Lee

Daniel M. Raybin

Carolyn D. Mar

Michael H. Siu

Rodman S. Rogers

Richard L. Caplin

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Brian J. Lewis

Gary L. Chan

Michael Rokeach

George A. Fouras

Jordan Shlain

Jeffrey Newman

Alan M. Teitelbaum

Thomas J. Peitz CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate Judith L. Mates, AMA’s Women Physicians Congress Governing Committee

Don’t Procrastinate: Get Your National Provider ID Today In less than a year, physicians who are covered by HIPAA will be required to use their new National Provider Identifier (NPI) on claims and other electronic health care transactions. All physicians

 San Francisco Medicine November 2006

who bill Medicare—even if not covered by HIPAA—must also obtain and begin using NPIs by the May 2007 deadline. NPIs will replace UPINs and other payor-specific provider identification numbers. Beginning May 24, 2007, Medicare providers and physicians covered by HIPAA will have their claims denied if they do not have NPIs. This is not an idle threat. Physicians will have had two full years to get their NPIs. Physicians are strongly urged to apply for NPIs immediately, if they haven’t already done so. Because many health care providers are expected to wait until the last minute to apply for their NPIs, there will likely be a backlog of applications in the months leading up to the deadline. Applying for an NPI is fairly simple. Physicians can apply online at https://nppes. cms.hhs.gov. If you do not have Internet access, call the NPI Enumerator at (800) 465-3203 and request a paper application form. While applying for an NPI is straightforward, making sure your billing systems and vendors are ready for the transition is a more complicated process, one that requires some preparation and internal assessment. CMA’s HIPAA partner, PrivaPlan, has developed an inexpensive CD-ROM toolkit to help physicians navigate the process. The toolkit will help physicians understand their NPI “readiness” and the impact the NPI may have on their practices. It also provides form letters and surveys to send to your major system vendors, clearinghouses, and health plans, to determine their NPI readiness. CMA members can purchase the toolkit for $99. CMA members who have purchased PrivaPlan’s other HIPAA toolkits pay $79. Nonmembers pay $129. Order the toolkit by calling (877) 218-7707. For more information, contact CMA’s legal information line, (415) 882-5144 or legalinfo@cmanet.org.

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DHS Develops New Name-Based HIV Reporting Form On April 17, 2006, a new California law took effect requiring physicians and other health care providers to report cases of HIV infection to health officials using patients’ names. Previously, such cases were reported using alphanumeric codes created from birth dates, gender, and elements of patients’ last names. This change was the result of a CMAsupported “urgency” bill (SB 699), which requires California physicians to immediately begin using patient names when reporting HIV cases. In response to the new law, the California Department of Health Services (DHS) has developed a modified HIV/AIDS reporting form. The revised form can be downloaded from the DHS website, www. dhs.ca.gov/aids. DHS has one year to develop and implement the regulations. Until the regulations are implemented, physicians can continue using the old case report form, with the addition of the patient name. Use of the modified reporting form will be mandatory once the regulations take effect. The code-based reporting system was created in 2002 to ensure patient confidentiality, but it proved to be a bureaucratic nightmare for health officials, and the resulting data was unreliable. The Centers for Disease Control and Prevention does not consider code-based HIV reporting to be accurate, and federal officials have said they will withhold funds from states that use code-based reporting rather than namesbased reporting.

Don’t Forget to Complete Pain CME before December 31 Deadline! California law (AB 487) requires physicians to complete twelve hours of continuing medical education (CME) in pain management and the care of terminally ill and dying patients. Physicians have until December 31 to satisfy this requirement. CMA’s Pain Conference: December 1–2, 2006 www.sfms.org

Pain, Palliation, and Politics: Pain Management and End-of-Life Care in California’s Regulatory Environment Disneyland Hotel in Anaheim, California This practical two-day CME program will be tailored to meet the needs of physicians who do not specialize in pain medicine. Offering 14 hours of Category I CME, this program completely fulfills California’s AB 487 mandate. For more information, contact CMA’s seminar line at (415) 8823330 or e-mail kdefabrique@cmanet.org.

CMA Calls Proposed DMHC Regulations Illegal and a Threat to Patient Care CMA filed comments on proposed regulations that would prohibit billing patients for emergency services provided by noncontracting physicians, calling the proposals “flatly illegal” and a threat to the quality and availability of emergency care throughout the state. The regulations would also establish an unproven and burdensome billing dispute resolution process and impose other unwarranted rules that would undermine fair and timely physician reimbursement. CMA delivered to the Department of Managed Health Care (DMHC) extensive written comments, supported by more than 4,500 pages of evidence. These comments supplement the compelling testimony presented by hundreds of CMA member physicians during three public hearings on the proposed regulations, including the third and final hearing in Sacramento. As was the case at the previous two hearings, more than forty CMA physicians delivered a strong and consistent message: Physicians don’t want to bill patients, and DMHC should ensure that insurance companies—whose profits continue to soar—pay fair and legitimate ER bills. For more information, contact Susan Bassett at (916) 444-5532 or sbassett@ cmanet.org.

New EMTALA Regulations Require Specialty Hospitals to Accept Transfers

The Centers for Medicare and Medicaid Services recently made some changes to Emergency Treatment and Labor Act (EMTALA) regulations. The new rules, which took effect October 1, clarify that all hospitals, even specialty hospitals without emergency departments, must accept patient transfers from other hospitals as required by EMTALA. The new regulations also authorize nurse-midwives and other qualified personnel acting within their legally authorized scope of practice to certify false labor. Previously, the EMTALA regulations required a physician to certify that a woman was not in “true” labor. For more information, contact CMA’s legal information line at (415) 882-5144 or legalinfo@cmanet.org.

Blue Cross Withdraws Controversial Endoscopy Payment Policy Blue Cross agreed to withdraw a controversial payment policy that cut physician reimbursement by 20 percent for endoscopic procedures performed in outpatient hospital settings and that gave 5 percent bonuses for procedures done in doctors’ offices or Blue Cross-contracting surgery centers. In May, CMA protested the new policy with state authorities, saying the rule places corporate profits ahead of patient care and safety and is likely illegal. CMA believes that it violates the state insurance code, which requires that medical decisions be “unhindered by fiscal and administrative management.” Blue Cross announced its decision to withdraw the policy after the Department of Managed Health Care (DMHC) filed a brief with the court, saying that the plan failed to obtain DMHC approval before making such a significant policy change, as required by state law. DMHC said in its brief that to obtain such approval, Blue Cross would have to justify why it should be exempt from Health and Safety Code section 1348.6, which outlaws payment incentives designed to deny, limit, or delay patient access to specific services.

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CMA is urging Blue Cross to readjudicate claims for endoscopic procedures performed in outpatient hospital settings that were paid between July 1 and October 4 (the dates the policy was in effect). For more information, contact Aileen Wetzel at (916) 444-5532 or awetzel@ cmanet.org.

Physician and Patient Action Needed to Avert Medicare Crisis If Congress does not act before the end of the year, Medicare payments to physicians will be cut by 5 percent on January 1 and by a total of 37 percent over the next six years. These cuts come at a time when medical practice costs are soaring. Over the last five years, the average cost to run a medical practice has gone up at least 18 percent, yet Medicare is still paying physicians the same rates it did in 2001. By 2007, Medicare physician payment rates will effectively have fallen by more than 20 percent. Congress needs to hear from both physicians and patients that inaction is not acceptable. Call, write, or visit with your members of Congress to express your outrage and extreme disappointment that the Republican leadership in Congress failed again this year to fix the physician payment problem. They need to understand that this is an urgent issue and that failure to reform the Medicare payment formula will force physicians to stop accepting new

Medicare patients or withdraw from the program entirely. Please urge your members of Congress to stop the 5 percent payment cuts during the post-election lame-duck session in November. Tell your members of Congress to dump the flawed SGR physician payment formula and replace it with a new formula based on the medical economic index, which would increase physician payments by 2.8 percent in 2007. Please also urge your representative to show the House leadership that he or she supports Medicare payment reform by cosigning the Medicare “Dear colleague” letters that are circulating in Congress. To contact your members of Congress, please call AMA’s grassroots action hotline at (800) 833-6354. You will be prompted to enter your zip code and will be automatically connected with your local representative. AMA has also published a flyer that physicians can use to inform patients about the impending crisis and encourage them to call their members of Congress to demand immediate action. Visit www.cmanet.org for more information, including talking points, sample letters, and AMA’s patient flyer. For more information, contact Elizabeth McNeil at (415) 882-3376 or emcneil@cmanet.org.

CMA Tip: Appeal Zero-Pays Four percent of the average practice’s monthly billed charges are “paid” by insur-

Upcoming Events November 29, 2006 Universal Health Care Access in San Francisco: Reality or Dream? California Pacific Medical Center, 5:30 p.m.–7:70p.m., SFMS and CPMC’s Program in Health and Human Values will present a forum on the ongoing effort to provide access to health care for every San Franciscan. For information and to RSVP, contact Steve Heilig at the SFMS at (415) 561-0850 extension 270 or heilig@sfms.org.

November 30, 2006 SFMS Symphony Night Enjoy a preconcert reception with hors d’ouevres and beverages and a vibrant program of Rachmaninoff and Tchaikovsky conducted by Vladimir Ashkenazy. Orchestra seats are $77.00, first tier are $67.00.  For more information, or to order tickets, contact Therese Porter in the Membership Department at (415) 5610850 extension 268 or tporter@sfms.org.

 San Francisco Medicine November 2006

ers at zero dollars. These “zero-pays” are effectively the same as denials but are not recorded as such. Zero-pays typically occur because the payor claims that the service is part of a bundled or global service for which it has already paid. Because zero-pays are typically related to payor-specific idiosyncrasies, there is little you can do to prevent them. But nearly three quarters of zero-pays can be successfully appealed. For more information, contact CMA’s Center for Economic Services at (916) 5512061 or jthompson@cmanet.org.

California Insurers Must Now Cover HPV Testing Governor Schwarzenegger recently signed a CMA-sponsored bill that requires California insurers to immediately begin covering human papillomavirus (HPV) testing as part of cervical cancer screening. The law, which makes California the fifth state in the nation to require coverage of HPV testing, underscores the test’s role as an emerging standard of care in cancer screening. Digene Corporation manufactures the only FDA-approved test for high-risk strains of HPV. The test is approved for use along with a Pap smear to screen women age 30 and older, the group most at risk for cervical cancer. For more information, contact Sandra Bressler at (415) 882-5171 or sbressler@ cmanet.org.

January 28-30, 2007 UCSF-CHE Summit on Environmental Challenges to Reproductive Health and Fertility Mission Bay Conference Center, UCSF, San Francsico. This summit will provide overviews by leading researchers of science and environmental contaminant impacts on reproductive health and fertility. Contact Mary Wade for more information, (415) 476-2563, or wadem@obgyn.ucsf.edu.   www.sfms.org


president’s Message Gordon Fung, MD, MPH

ExtraOrdinary Medicine

I

n this month’s issue of San Francisco Medicine we will look at some advanced and unusual practices in medicine, many of which can be described as extraordinary. Doing something extraordinary to help others is probably what we as physicians all dreamed of doing before we entered medical school. We looked at medical school as the place to learn exceptional knowledge and skills so that we could help patients relieve pain, treat disease, and improve the health and well-being of the community. It was more than altruism or blind optimism; it was motivation and energy that got us through the pre-med years and helped us through the grueling hours and nights of training to become healers. The dream of being creative in applying one’s knowledge to develop new ways to heal the sick is very real for all physicians. This is the motivating force behind research and development into new surgical techniques, new devices, new medications, and, on occasion, new combinations of older medications to treat a disease different than the original indication for that medication. Thanks to this drive, healing using laughter, massage therapy, music therapy, pets, and many other new approaches have become more commonplace. But times are changing, and so is medicine. New approaches, devices, and therapies are increasingly being left to a select few that are in research, at research-oriented medical centers, or whose practices are not dependent on third-party payers. Why? Because the current culture of medical delivery is very resistant to change. We spent the last decade looking at the practice patterns of the vast majority of practitioners. What we found was a wide variety of practices and outcomes. So the health care system of quality experts, with the support of clinical researchers and the payers, have spent

untold hours developing measures, guidelines, and credentialing and certification programs to deliver only the highest quality of care to our patients. The next step, which is already happening in some centers, is to digitize our entire medical record keeping and documentation to be able to electronically analyze the outcomes of our practice according to specific guidelines, e.g., how many diabetics are referred to ophthalmology; how many at-risk patients are given flu vaccines; how many cardiac patient are on aspirin, statins, and beta-blockers. From here, the next step is to reimburse practitioners based on their performance on these measures—the so-called P4P. At the beginning, it may take the form of a bonus if achievement is high; but it is conceivable that in the not-too-distant future, one may not be reimbursed if measures taken do not meet a certain predetermined standard. Although the goal to have a uniform standard of the highest-quality evidenced-based care is admirable, I feel that it may consequently squelch the innovative spirit that allows people to develop extraordinary approaches in medical practice—especially if experimentation brings with it the risk of a physician not getting paid for not meeting a predetermined goal. On the other hand, this paradigm shift to performance-driven reimbursement could have the stimulating effect of encouraging the entrepreneurial and creative spirit to meet target guidelines with modifications in practice style, team building, and even newer technologies. I would hope that we as physicians will never lose that creative spirit, since our primary motivator should be to do our absolute best for our patients. I’m hoping that this issue is one of many to come in which we can celebrate some of the more extraordinary accomplishments in medicine.

Congratulations, Dr. Fung! SFMS President Gordon Fung, MD, was appointed by Governor Arnold Schwarzenegger and the Director of Health Services, Sandra Shewry, to the Council on Multicultural Health. This council was established to provide California Department of Health Services (CDHS) with expert advice on needs and issues related to the health of California’s diverse communities and to improve communications between CDHS and the communities it serves. Since its creation in 1993, the council has proven to be an invaluable resource to the director and to key programs throughout the department. Some of the program areas in which it has been active include Medi-Cal Managed Care, Family Planning, Domestic Violence Prevention, Immunization, Refugee Health, and AIDS/HIV. The council has also sponsored a series of Community Forums throughout the state in conjunction with its quarterly meetings. Dr. Fung will serve a three-year term and will be eligible to serve up to two consecutive terms.

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november 2006 San Francisco Medicine 


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DEPARTMENT TITLE HERE Editorial Mike Denney, MD, PhD

Extraordinary Healing In 1929, a German surgical resident, Werner Forssman, did something extraordinary. Against the wishes of his Chairman of Surgery, Forssman dissected his own antecubital vein, inserted a urological catheter, and guided the catheter by fluoroscopy through his subclavian vein, down his superior vena cava, and into his heart. He then walked to the radiology department and, with an X-ray film, documented the position of the catheter tip in the right atrium. He was promptly dismissed from his residency for performing such an audacious, frivolous, and dangerous act. However, we engage the theme of extraordinary healing in this issue of San Francisco Medicine. And with this in mind, your Editor has good reason to recall this tale of Dr. Forssman. Why? Because while hiking on Mount Tamalpais a few weeks ago, this same Editor experienced vague, generalized chest pain. Though enjoying a thorough state of denial, he nevertheless condescended to heed his companions’ advice to stop and rest. When the pain did not abate, he reluctantly allowed himself to be hauled up the mountain to a waiting ambulance. Later, after evaluation by his cardiologist, Sophie Barbant, MD, he was taken to California Pacific Medical Center, where he underwent an angioplasty performed by Bruce Brent, MD, to open a 90 percent occlusion of his right coronary artery. After recovering, he discovered the intriguing continuation of the story about the audacious young Dr. Forssman. After his misadventure in 1929, Forssman was reinstated as a urological surgery resident (a field in which presumably he would more appropriately apply his catheters), and, ironically, in 1956 he was awarded a Nobel Prize for having performed the first cardiac catheterization. Thank you, Dr. Forssman, for forging the path that led from an experimental cardiac catheterization in 1929 to a particular angioplasty in 2006. Of course, Forssman wasn’t the first or the last doctor to resort to extraordinary methods in order to achieve results. In 1895, acting in the spirit of Semmelweiss before him, William Halsted, the father of American surgery, erected a surgical tent in a courtyard outside of New York’s Bellevue Hospital in order to practice aseptic technique, which was disallowed inside the hospital because it had not yet been scientifically proved that the “animacules” seen under the microscope were the cause of infections. The annals of medicine are filled with the names of such adventurers into extraordinary healing—Walter Reed, Carl Landsteiner, Oliver Cope, Helen www.sfms.org

Taussig, and Alfred Blalock, to name just a few. Perhaps the boldest of these pioneers was Franny Moore, chief of surgery at Harvard’s Peter Bent Brigham Hospital from 1948 to 1976, who, in his early career, believed that in desperate situations, doctors should use extraordinary measures. In this spirit, Moore charged ahead where the less heroic hesitated, removing pituitary and adrenal glands as part of treating metastatic breast cancer, advancing mitral valvulotomy and artificial heart utilization, and performing kidney and liver transplants before immunosuppressive therapy was known. Later in his career, however, Moore seemed to have a change of heart. In the late 1960s, alarmed by the 100 percent incidence of agonizing death of recipients, he halted liver transplants. He also publicly denounced implantation of artificial hearts and heart transplants, saying that these procedures needed further research before being applied to humans. In the spirit of William Osler, as if to emphasize his more caring frame of mind, Moore wrote a handbook entitled The Dignity of the Patient, and he required all of his residents to read it. And so it is that, when contemplating this issue’s focus on on extraordinary healing and his own recent angioplasty, your Editor also finds good reason to tell the tale of the older and wiser Franny Moore. Moore’s later philosophy, like his early experimentation, pointed toward the future. In the early 1980s, for example, Angie Thieriot, Patty Phelan, Robin Orr, and many others developed the original Planetree project, including the public medical resource library and the extraordinary 13-bed, experimental “patient-oriented” inpatient unit at California Pacific Medical Center, in which the dignity of the patient was foremost in design, organization, and practice. The dream was that someday the entire hospital would be like a Planetree unit. Your Editor can confidently report that apparently that dream has come true. In his recent stressful experience at California Pacific Medical Center, the entire process was clearly patient-oriented. Each individual person among the secretaries, clerks, nurses, doctors, and transport personnel—those at the registration desk, in the preop unit, the invasive cardiology room, and the post-op cardiac care unit—was friendly, helpful, and caring to an extraordinary degree. Your Editor learned in a most personal way that, from a patient’s point of view, all healing is extraordinary. november 2006 San Francisco Medicine 


Extraordinary Medicine

Nanotechnology and Medicine How Will this Emerging Field Impact the Way Physicians Treat Patients? David W. Stretavan, MD, PhD

I

t seems we see and hear the word nanotechnology all the time now. Being in the Bay Area, with Silicon Valley and the nation’s best research universities, perhaps we are more exposed to the term than others. All the more reason to find out why there is such a buzz around nanotechnology and how it might impact medicine and the way physicians take care of patients. First of all, a definition: nano comes from the Greek word for “dwarf.” That seems appropriate, since the term is used to designate a very small unit of metric measurement. A nanometer is exactly one billionth of a meter. To put that in perspective, a human hair is roughly fifty microns, or about 50,000 nanometers, in diameter. Approaching it from the other end of the scale, a nanometer is equivalent to ten angstroms, or ten times the diameter of a hydrogen atom. A collagen fibril is 300 nanometers in diameter, while the diameter of a DNA double helix is 2.5 nanometers. Biomolecules are, therefore, all sized in the nanometer scale; and human biology as well as pathology in some sense reflects events in the nanoworld, multiplied many, many times over. Nanotechnology is generally taken to mean the area of human endeavor in which matter is manipulated at near-atomic scale. Useful properties that exist at the nanoscale are exploited for use in the macroworld. The essence of nanoscience was captured in a talk titled “There’s Plenty of Room at the Bottom: An Invitation to Enter a New Field of Physics,” given by Richard Feynman in 1959. In this speech, Feynman conveyed the excitement and potential of nanotechnology, planting the seeds for what is now a very dynamic and fast-moving field of science.

Since biochemists and molecular biologists have always been interested in proteins and DNA, are they not nanotechnologists? Yes, but nanotechnology also refers to the manipulation of biological material to create novel structures with novel functions,

how the world around us works according to laws of Newtonian physics, the nanoworld, in which quantum mechanics predominate, is unfamiliar. For instance, a given material in bulk versus a nanoscale quantity of the same material can have very different optical and electronic properties. Nanocrystals of semiconductive material that vary slightly in size will emit different colors of light due to a principle called the quantum confinement effect. This effect, which is seen only at the nanometer scale, is the basis of new fluorescence agents called quantum dots, which are now commercially available and very useful as versatile visualization reagents in biological research. A discussion of nanotechnology would be incomplete without a few words on the quintessential nanomaterial, carbon nanoincluding hybrid biological and engineered tubes. Carbon nanotubes are exactly what entities. This idea of biological machines their name implies: very small tubes made crystallized in 1999, when Carlo Monte- completely of carbon. Discovered in 1991 magno found a way to specifically bind na- by Sumio Iijima, they are a good example noscale ATPase molecular motor proteins of new materials that have unique and thus onto an engineered surface. The application potentially valuable electronic, thermal, of ATP then allowed these nanomotors structural, and other properties. For exto actively spin a bead attached to the ample, some types of carbon nanotubes are central protein shaft. In one stroke, these better conductors than copper; and they researchers demonstrated that it was pos- can reach up to one hundred times the sible to make a nanoscale machine capable strength of steel at one sixth the weight. of performing work, and that biology itself New properties of carbon nanotubes are may in fact be a rich source of interesting still being discovered, and they have been nanoscale devices. The idea that we can touted as components for future molecular learn from nature and develop new materials computers, spacecraft components, and drug and devices modeled after biology has blos- delivery devices, to name a few. The fact somed into a very active area of biomimetic that nanomaterials have very useful propernanotechnology research. ties and can therefore improve a wide range The excitement about nanotechnol- of existing products has taken hold. One can ogy is not only that it deals with extreme now find nanotechnology incorporated into miniaturization. It is that working at the such everyday items as household paints, nanoscale opens up the world of quantum cosmetics, and fabric for clothing. mechanics. While we are all familiar with Nanotechnology is beginning to per-

“While we are all familiar with how the world around us works according to laws of Newtonian physics, the nanoworld, in which quantum mechanics predominate, is unfamiliar.”

10 San Francisco Medicine November 2006

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meate and influence our daily lives. What is also clear is that nanotechnology could potentially have a large impact on the delivery of health care. Recognizing this, the National Institutes of Health, under current leader Elias Zerhouni, have made nanomedicine one of the pillars of their new roadmap. The mission of this initiative is to harness the benefits of nanotechnology, better understand the inner workings of cells, develop new and better methods of diagnosis and therapy, and invent new medical instrumentation that can provide the physician with unprecedented capabilities in disease treatment. Cancer research and treatment is an area of medicine that has quickly adopted nanotechnology to serve its cause. For instance, nanoparticles have been coated with molecules that allow them to home in on cancer cells. Once finding these target cells, the nanoparticles can deliver a drug for cell-specific killing. Another method uses gold-coated nanoparticles to bind cancer cells, then to expose the nanoparticles to near-infrared light to heat them up and destroy the malignancy. Specially concocted nanoparticles are also being used to encapsulate anticancer agents that are poorly soluble in water. The idea is that the small size of the nanoparticles will allow them to travel to tumor sites and enable local, stable release of chemotherapeutic agents. In addition to their uses in treatment, nanoparticles are also being developed as highly sensitive imaging contrast reagents that may allow the detection of cancer development in as few as a handful of cells in the human body. Another area that may soon see the impact of nanotechnology in the near term is drug delivery. Nanoparticles are being custom-designed with molecular recognition properties to carry drug particles to specific sites of the body. Due to their small size, nanoparticles can also bypass the blood-brain barrier, which can normally

impede drug delivery. The pharmacokinetics of specific drugs can also be modified in interesting ways by coupling them to nanoparticles, since the circulation time, clearance, and tissue extravasation characteristics of nanoparticles can be specifically engineered. For example, paclitaxel, when delivered with nanoparticles of albumin, does not require toxic solvents in its formulation and thus allows substantially larger amounts of the drug to be delivered to patients. While nanotechnology research is taking place at a breathtaking pace, some nanotechnologists have voiced concern about the safety of nanomaterials. Medicine is familiar with the relationship between small particulate matter and the development of mesotheliomas. What about new nanoscale materials? Although there is no clear consensus yet, there have been some reports that animals exposed to nanoparticles show signs of pulmonary pathology. The long-term effects of nanosubstances implanted into the human body are also currently unknown. Larger questions include the environmental impact of nanomaterials that may one day be produced in industrial quantities. With all of the current research into nanotechnology and its medical applications, what will the nanomedicine of the future look like? Of course it is still too early to tell, but one possibility is that it may not look too different from medicine as we know it today. The main reason for this is that, due to its size, the nanotechnological component may well be invisible to the user. Unlike such technological innovations as computed tomography and magnetic resonance imaging, which literally changed the medical landscape because of the size of the required instrumentation and special housing facilities, the integration of nanocomponents into medicine, from materials to drug delivery, may be pervasive but not visually obvious to the physician or the patient.

“It is clear is that nanotechnology could potentially have a large impact on the delivery of health care. Recognizing this, the National Institutes of Health have made nanomedicine one of the pillars of their new roadmap.�

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A highly plausible future scenario is that increasing medical use of nanotechnology, because of its capacity for miniaturization and novel capabilities, will give birth to a vast array of minimally invasive procedures both for diagnosis and for therapy. This science of the future, should it come to pass, may dovetail nicely with the demographic trend of an aging population. This alreadyoccurring shift in demographics may in fact bring about significant economic pressures that push nanotechnological advances into medicine more quickly.

David W. Sretavan obtained his MD and PhD degrees from Stanford University, where he performed graduate work in neurobiology. In 1994, after postdoctoral work at Rockefeller University and the Howard Hughes Medical Institute at UCSF in cell and molecular biology, Dr. Sretavan joined UCSF, where he is now Professor of the Departments of Ophthalmology and Physiology. He is an active member of the neuroscience, biomedical science, and bioengineering graduate programs at UCSF, as well as a member of the California Institute for Quantitative Biomedical Research (QB3). He also serves as a council member for the UCSF Medical Scientist Training Program (MSTP) and is Vice-Chair of the Department of Ophthalmology. Dr. Sretavan is an advisor for the UCSF Center for Bioentrepreneurship (CBE) and serves in an advisory capacity for national and international medical research funding agencies, as well as for leading scientific journals. A major interest of Dr. Sretavan’s is the application of new technologies to enable medical procedures at an unprecedented small scale. In 2005, Dr. Sretavan received a major research award from the Sandler Foundation for his innovative work on a novel microscale system and nanodevices for nerve-cell repair.

Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from full-page 4-color display ads to classified ads with discounted rates for members. Please contact Galen Foster for more information, (415) 561-0850 extension 240 or foster@sfms.org.

november 2006 San Francisco Medicine 11


Extraordinary Medicine

New and Old Approaches to Healing Research at the University of California San Francisco’s Osher Center for Integrative Medicine Frederick Hecht, MD

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ecent data show that more than a third of American adults use complementary or alternative medical (CAM) therapies each year—many of which have been in use for hundreds of years. These treatments offer the promise of ameliorating conditions that are not adequately helped by conventional medicine. Simply withstanding the test of time does not prove benefit and safety, however, as examples from conventional medicine, such as the use of postmenopausal estrogen replacement therapy, attest. The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health addresses these issues under the term integrative medicine, which it defines as medicine that “combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.” The research program of the UCSF Osher Center for Integrative Medicine is part of an international effort to expand the evidence base for integrative medicine practices. One important goal is to increase the therapeutic options available to medical practitioners and to integrate evidence-based approaches into existing medical practice. In some cases, this research indicates that CAM therapies either are not safe or may not be effective. Osher Center-affiliated researcher Dr. Steven Bent has obtained both results in his research on botanicals. A 2003 study found that ephedra use was associated with a greatly increased risk for adverse reactions compared with other herbs (Bent et al. 2003). This study was one of the pieces of evidence that led the FDA to

restrict the sale of ephedra. A recent study of saw palmetto by Dr. Bent and others (including Dr. Andrew Avins, another Osher Center-affiliated researcher) found that there was no evidence for its efficacy in benign prostatic hypertrophy, in a carefully performed, randomized, controlled trial (Bent et al. 2006). But recent studies by Osher Center researchers have shown promise for other practices. Clinicians at the Center developed a program, dubbed the Perioperative Integrative Medicine Service (PIMS), that offered massage and acupuncture to postsurgical oncology patients at UCSF. Osher Center researchers tested its efficacy in a randomized,controlled trial. This study found that patients who received the PIMS intervention reported a decrease of 1.4 points on a pain scale of zero to ten, compared to 0.6 in the control group (P = 0.038) during the postoperative period, and a decrease in depressive mood of 0.4 (on a scale of one to five) compared to plus or minus zero in the control group (P = 0.003) (Jacobs et al. 2006). Osher Center researcher Dr. Wolf Mehling recently conducted a study of breath therapy for low back pain (Mehling et al. 2005). Breath therapy is a Western mindbody therapy, developed in Germany in the 1920s, that integrates body awareness, breathing, meditation, and movement. In this study, patients suffering from chronic low back pain, a challenging problem to treat, were randomized to receive breath therapy or high-quality physical therapy. Patients improved significantly with breath therapy, showing changes in standard measures of pain and disability that were

12 San Francisco Medicine November 2006

comparable to those from high-quality, extended physical therapy. Mind-body therapies are in fact a key focus of current research at the UCSF Osher Center for Integrative Medicine. The Center is the recipient of a program project grant from the NCCAM Center for Excellence in Research on Complementary and Alternative Medicine. In this project, the Staying Well study, researchers are performing a randomized, controlled trial of Mindfulness Based Stress Reduction (MBSR) in early HIV infection. This study, based on observational data, shows that stress and depression are both associated with more rapid loss of CD4+ T cells. Little is known about whether interventions that address stress and mood are capable of slowing the loss of CD4+ T cells, however. In prior trials, MBSR has been shown to reduce perceived stress and improve mood. The Staying Well project also aims to assess whether MBSR has these effects on study participants, thus improving their quality of life, in addition to assessing any impact of the intervention on CD4 T-lymphocyte cell counts and HIV-RNA levels. The study will also assess in detail the effects of the intervention on stress hormones and test specific mechanisms through which stress and mood may alter HIV-related immune function. The UCSF Osher Center aims to continue expanding our knowledge base about well-researched approaches in integrative medicine. More information about the Center’s work and its research program can be found at www.osher.ucsf.edu.

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Extraordinary Medicine

Expanding Life Reflections on a Complete Remission of Advanced Cancer Michael Lerner, PhD

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an Gawler, an Australian veterinarian, was diagnosed with an osteogenic sarcoma in 1975. His right leg was amputated at the hip. The cancer recurred later that year; he had a large tumor in his chest. In March 1976, he was told he had weeks to live. Ian and his wife started a vigorous program of alternative therapies. A psychiatrist named Ainsley Meares believed that deep meditation on a sustained basis might help reverse cancer. Gawler, who was also a decathlete, became a dedicated meditator, sitting for many hours each day. He also began to eat the Gerson Diet, one of the most rigorous of the raw-foods cancer diets. He visited psychic healers in the Philippines and went to India to see the spiritual teacher Sai Baba. In June 1978, he was declared free of active cancer. When I met Ian two decades later, he was the director of the Gawler Foundation in Melbourne, Australia. I went to the Foundation to participate in his residential programs for cancer patients; at another point he came to Commonweal, in Bolinas, California, where for more than twenty years we have offered weeklong retreats for people with cancer. Ian believed without a doubt that people could recover from metastatic cancer by following intensive regimes like the one he undertook. He tells his story in You Can Conquer Cancer (Hill of Content, 1984). Complete remissions from advanced cancer are, in fact, well documented. Brendan O’Regan of the Institute of Noetic Sciences produced a pioneering survey of the medical literature, Spontaneous Remissions: An Annotated Bibliography (Institute of Noetic Sciences, 1993), in which he and Caryle Hirschberg reviewed many of the studies. He also attempted to analyze common www.sfms.org

factors in recoveries. Some are associated with removal of a primary tumor, some with a high fever, some with dietary interventions, and some with deep psychospiritual transformation. The interesting question is whether complete remissions of advanced cancer are an isolated curiosity or are at the end of a distribution curve of ordinaryto-exceptional survival. From twenty years of work in the Commonweal Cancer Help Program, I firmly believe the latter. While I have seen few complete spontaneous remissions, I have witnessed many people who survived far beyond expectations. Median survival rates are, I believe, not the right indices of life expectancy for motivated, engaged cancer patients. For one thing, tragically, economic and ethnic disparities in health outcomes pull the survival medians downward. Equally important, performance or functional status is a known predictor of survival in many cancers. Hence patients who undertake intensive health promotion practices that improve functional status would be expected to live longer. The physical, mental, emotional, and spiritual factors that contribute to those rare complete remissions may more frequently contribute to extended survival. But because the specific configurations of the interventions that appear to help individual patients are quite specific to their unique psychological and biological conditions, very few scientific studies of limited interventions, such as a support group or moderately improved diet, capture the extent of the survival gains that some individual patients achieve. This means that, at the end of the day, we cannot “prove” that unique gestalts of integrative approaches to cancer by engaged individual patients contribute to the sometimes remarkable extensions of life they achieve.

We also cannot prove that these efforts do not contribute to survival. As my colleague Rachel Naomi Remen says, whether or not we can extend life by such efforts, we can unquestionably expand life by inner work. With respect to expanding life, miraculous experiences of healing are far more common. For healing, we know, is fundamentally different from curing and can take place at any point in the illness cycle. Healing takes place in living and, equally powerfully, in the dying process. This observation is nothing new. It is documented in all the great spiritual and philosophical traditions. When disease or any other tragedy of life strikes us, our busy lives are suddenly brought to a standstill. A whole new vista suddenly opens—or, if we are in touch with our inner lives, deepens—before us. Real physicians and healers understand the uniquely important role they play for their patients in the healing journey. I never discourage a patient who seeks to achieve extraordinary life extension with a difficult cancer. But I always encourage the patient to see that the mechanisms that demonstrably support life expansion are also the mechanisms that may contribute to life extension. And many patients are not focused on achieving remarkable life extension. They do not want to undertake the heroic efforts Ian Gawler made in such areas as meditation and dietary change. What is far more likely to draw them is the inner psychological and spiritual work of healing. Their achievements in this realm often stagger the imagination. Michael Lerner is President and Cofounder of Commonweal, a health and environmental research institute in Bolinas, CA, and of Smith Farm Center for Healing and Arts in DC.

november 2006 San Francisco Medicine 13


Extraordinary Medicine

Brachytherapy for Prostate Cancer One Hundred Years and Getting Better Mack Roach III, MD; I-Chow Hsu, MD; Alex Gottschalk, MD, PhD; Joyce Speight, MD, PhD; and Katsuto Shinohara, MD History of Brachytherapy for Prostate Cancer he term brachytherapy is derived from the Greek root brachy-, which means “short distance.” Brachytherapy refers to techniques of delivering radiation by placing radioactive sources (usually in the form of seeds) directly into or in close proximity to the tumor. The unique advantages associated with the use of brachytherapy result from the fact that when radioactive sources are placed within the treatment volume, the radiation travels from within outward. In contrast, with external beam radiation (EBRT), the radiation travels through normal tissues to reach the target. Thus with brachytherapy, the amount of normal tissue the radiation has to travel through to reach its target is minimized, so that deep-seated tumors can be treated without radiating the skin or other dose-limiting organs. Shortly following the discovery of radium in 1898, brachytherapy became an important part of cancer therapy. The application of brachytherapy to treat prostate cancer dates back to the beginning of the twentieth century, decades before the development of high-energy EBRT and prior to the development of the modern radical prostatectomy. By the early 1900s, radium was used in the treatment of carcinoma of the bladder and prostate cancers (Degrais and Pasteau 1914, Barringer 1917). However, it was not until the 1970s, when the radioactive seeds became available and an open implant technique was developed, that brachytherapy begin to be routinely used to treat prostate cancer (Whitmore, Hilaris,

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and Grabstald 1972). The open brachytherapy technique involved retropubic exposure of the prostate and the “freehand” insertion of needles loaded with radioactive iodine I-125. The needles were inserted via direct visual inspection and palpation of the needle tips

in the rectum. Using this technique, it is now clear that the accuracy and thus quality of the radiation dose distributions were frequently inadequate. This resulted in frequent local failures and a relatively high rate of complications. These problems, combined with the development of highenergy linear accelerators and the nerve sparing radical prostatectomy, resulted in a decline in the interest in prostate brachytherapy. In the early 1980s, a new prostate brachytherapy technique was developed that involved transperineal placement of needles under transrectal ultrasound (TRUS) guidance. Using TRUS guidance (Figure 1), the placement of the needles could be monitored in real time and the probability of consistent and accurate placement improved dramatically. Two other major advances that fostered the further evolution of brachytherapy were the avail-

14 San Francisco Medicine November 2006

ability of computers that allow reconstruction of the pelvic anatomy in 3-D and the development of sophisticated algorithms that allow radiation dose distributions to be calculated quickly. Modern Prostate Brachytherapy Permanent prostate implant (PPI) involves leaving the radioactive sources (most frequently Iodine-125 with a half-life of sixty days or Palladium 103 with a half-life of seventeen days) permanently in the prostate. More recently, cesium sources have also become available. During the brachytherapy, radioactive seeds are inserted into the prostate under TRUS guidance using needles. The most important determinant of the success of PPI is the accurate placement of the radioactive seeds needed for favorable radiation dose distribution. This depends on the expertise of the physicians and not the type of isotope used. Only when the proper radiotherapy is delivered can it lead to sterilization of all tumor cells located within the prostate and a low risk of long-term side effects. Another contemporary prostate brachytherapy technique involves radiation delivered via prostate implant using a robotic device called the remote afterloader. This approach is called “high dose rate” (HDR) brachytherapy. The radiotherapy is delivered in just a few minutes, in contrast to PPI, in which radiation is given out over months. During the HDR implant procedure, needle catheters are inserted into the prostate under TRUS guidance, which is similar to the PPI procedure. However, the radioactive source is not inserted manuwww.sfms.org


Transperineal-transrectal ultrasound-guided approach for permanent seed implant.

The three-dimensional brachytherapy planning system is an important part of modern brachytherapy. Critical organs such as the urethra, rectum, and bladder bulb of the penis are contoured during the treatment planning process, so the dose delivered to the critical organs can be accurately controlled. The blue-shaded region represents the treated volume.

Above is an example of HDR brachytherapy dose distribution. Very conformal dose distribution can be delivered to the prostate using the modern brachytherapy treatment system. A steep dose fall-off outside of the implant volume decreases the dose and volume of radiated normal structures.

ally but by a remote afterloader based on a computer-optimized treatment plan. Iridium Ir-192 is the most commonly used source for HDR implants (­­­­Figure 3). The radioactive source is removed after the appropriate dose distribution is delivered. Since the radioactive source is loaded outside of the www.sfms.org

operating room, the exposure to personnel is minimized. HDR prostate implants are usually administered using multiple fractionated treatments delivered over one or two inpatient stays. The HDR approach provides greater flexibility compared to PPI, particularly for delivering radiation to areas outside the prostate and into periprostatic tissues.

be considered to represent worst-case scenarios, because the technology used at the time was, as described above, very crude (Zelefsky and Whitmore 1997). Contemporary results from UCSF suggest PSA control rates approaching 95 percent for low-risk patients for whom the minimum follow-up from treatment is five years (Roach et al. 2005). It is of note that these results appear to be superior to those reported for similar patients treated with high-dose proton beam radiotherapy. At UCSF, we have also had extremely impressive outcomes for high-risk patients managed with HDR (Hsu, Cabrera, Weinberg et al. 2005). We analyzed a group of sixty-four patients who would be expected to have relatively poor outcomes (at least one of the following risk features: PSA>10, Gleason score (GS) > or =7, and clinical T3 disease) with any form of radiation or surgery. With a median follow-up of fifty months, we noted fouryear estimates of overall and disease-free survival were 98 percent and 92 percent, respectively. In general, morbidity was quite low, with only one patient experiencing late grade 4 gastrointestinal toxicity.

“With brachytherapy the amount of normal tissue the radiation has to travel through to reach its target is minimized so that deep-seated tumors can be treated without radiating the skin or other dose-limiting organs.”

Patient Selection for PPI and HDR At UCSF, patients with organ confined disease, as determined by transrectal ultrasound, are treated with permanent prostate seed implantation (PPI), either as a monotherapy (alone) or in combination with external-beam radiotherapy (EBRT). Patients with one or more adverse risk factors (PSA> 10 ng/ml, Gleason score > 6 or a > bulky T2b disease or multiple positive biopsies) are frequently treated with external-beam radiotherapy for five weeks before the implant. HDR is usually used as a boost in conjunction with EBRT. As a result, patients selected for HDR generally tend to have more adverse pretreatment features than patients treated with permanent implants. The relative contraindications to PPI include: (1) a combination of large prostate and narrow pubic arch that interferes with proper insertion of needle and the placement of seeds; (2) the presence of a large defect involving the urethra due to a prior transurethreal resection of prostate (TURP); (3) patients with very poor urine flow (they tend to become obstructed and require a catheter); and (4) patients with extension into the seminal vesicles or fat around the prostate. In some of these cases, HDR may be used despite these problems because of its ability to modify its dose distribution using computer-optimized treatment planning. Results of Brachytherapy Although there are several series reporting fifteen-year data, these should

Brachtherapy as a “Salvage” Therapy Approach after EBRT Because of our extremely favorable impressions of the success of both forms of brachytherapy in the primary management of men with localized disease (as described above), we have also used brachytherapy to treat a number of men with confirmed local recurrences after EBRT. Our preliminary experience with either PPI or HDR in this setting has been quite favorable. In a preliminary analysis of twenty-one consecutive patients treated with salvage HDR brachytherapy for locally recurrent prostate cancer after radiotherapy, the two-year biochemical control after recurrence was 89 percent (Lee et al. 2006). All patients were treated using Continued on page 30...

november 2006 San Francisco Medicine 15


Extraordinary Medicine

Marijuana for HIV-Related Conditions The Successes and Ongoing Challenges of This Treatment Option Donald Abrams, MD Medicinal Marijuana: A Brief History arijuana is one of the oldest known psychoactive plants with medicinal properties. First cultivated in China and India, marijuana arrived in the U.K. in the 1840s, where it was widely used to treat pain, inflammation, spasms, convulsions, and even—according to legend—Queen Victoria’s menstrual cramps. The advent of barbiturates and opiates, along with the federal Marijuana Tax Act of 1937 (which the American Medical Association opposed), caused interest in medical marijuana to wane in the United States. By 1942, marijuana had been removed from U.S. pharmacopoeia. In 1970, the Controlled Substances Act designated marijuana as a Schedule I substance, meaning that the potential for abuse was high, no accepted medical use existed, and doctors had to obtain a separate license to prescribe the drug, for research purposes only. Despite this political movement against marijuana, there have been consistent calls for more research into the drug’s potential medicinal uses. The1999 Institute of Medicine (IOM) report “Marijuana and Medicine: Assessing the Science Base” asserted that marijuana is safe and effective against nausea, appetite loss, vomiting, pain, and spasticity (Joy, Watson, Benson 1999). Almost all officially sanctioned reports have come to the same conclusion, and all have been largely ignored. In 1986, the FDA approved the use of dronabinol (Marinol®), which is synthetic tetrahydrocannabinol (THC, the most psychoactive part of the marijuana plant), to treat the nausea associated with chemotherapy. It expanded the indication in 1992 to include anorexia associated with

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HIV wasting syndrome. In doing so, the FDA endorsed at least one component of marijuana, tetrahydrocannabinol, as safe and effective for appetite stimulation and relief from nausea. The Treatment of HIV/AIDS Before the advent of antiretrovirals, patients succumbing to HIV wasting syndrome often smoked marijuana to increase their appetites. In 1992, Mary “Brownie” Rathbun—a 71-year-old IHOP waitress and former San Francisco General Hospital AIDS Program Volunteer of the Year for two years running—made international headlines when she was arrested in Sonoma County for making marijuana brownies for AIDS patients. The controversy introduced me to Rick Doblin, PhD, founder of the Multidisciplinary Association for Psychedelic Studies (MAPS), and ultimately led me to propose the first-ever study to validate the efficacy of smoked marijuana to increase appetite in HIV patients. Over the course of the next four years, both the National Institute on Drug Abuse (NIDA) and the National Institutes of Health (NIH) rejected the proposal, with peer reviewers calling it “unscientific” and labeling marijuana “a toxic substance.” At the same time, the political environment in San Francisco was becoming more favorable: Use of local cannabis buyers’ clubs was increasing, Proposition 215 gave California citizens the right to use marijuana for medicinal purposes, and the Center for Medicinal Cannabis

16 San Francisco Medicine November 2006

Research (CMCR) was established through the University of California. THC, Neuropathy, and Vaporization It was the introduction of a new class of antiretrovirals, protease inhibitors (PIs), in 1996 that provided the scientific hook to get our first study funded. Although amazingly effective in the treatment of HIV, the widespread use of PIs raised new health concerns, especially after one patient taking PIs died while using ecstasy (MDMA). Protease inhibitors, which can inhibit or stimulate the hepatic cytochrome P-450 enzyme system, are subject to many significant drug-to-drug interactions. The likelihood of an interaction with marijuana seemed possible, since cannabinoids are metabolized by some of the same cytochrome P-450 enzyme isoforms that metabolize PIs. So, in 1997, I submitted a new proposal for a prospective, randomized, placebocontrolled intervention study to examine whether cannabinoids—smoked or taken as dronabinol—interacted with protease inhibitors or the immune system in a way that altered HIV-RNA levels. Appetite and weight gain were analyzed as secondary outcomes. The study concluded that smoked and oral cannabinoids were not unsafe in people with HIV infection with respect to HIV-RNA levels, immune function (as measured by CD4+ and CD8+ cell counts), or protease inhibitor levels (Abrams et al. 2003). No significant changes in HIVRNA levels occurred for the dronabinol www.sfms.org


or smoked marijuana groups compared to a group receiving an oral placebo. CD4+ levels actually rose for both cannabinoid test groups, although increases were not statistically significant. Increases in CD8+ count were significant, but for the smokedmarijuana group only. Both cannabinoid test groups gained a statistically significant amount of weight compared to the placebo recipients. Following the initial safety study, our focus turned to assessing the effect of smoked marijuana on chronic pain. Scientists had been elucidating the effect of cannabinoids in the body for the past few decades. The cannabinoid receptor, CB1, was found in areas of the brain responsible for modulation of nocioceptive processing (Calignano et al. 1998). It also exerted analgesic activity throughout the central nervous system in animal models (Buxbaum 1972). Previous studies had found that intravenous THC exerted antinociceptive effects and that oral THC can offer pain relief equal to 120 mg of codeine, although with marked psychological effects (Avery et al. 1975). Based on this research, we conducted an initial, openlabel pilot test, funded by the CMCR, to evaluate the analgesic effects of smoked marijuana in patients suffering from HIVrelated peripheral neuropathy. To make results as objective as possible, relief from experimental pain was also evaluated, using a heat-capsaicin model. The study found that patients’ pain decreased by, on average, 50 percent when smoking marijuana. Pain returned after the study. Ten out of sixteen patients experienced a 30 percent reduction in average daily pain. These results allowed us to calculate the sample size and proceed to a fifty-participant, placebo-controlled, randomized-controlled trial. Like the pilot study, the RCT found that cannabis decreased neuropathic and experimental www.sfms.org

pain by a similar percentage and was more effective than the placebo (Abrams et al. 2006). Despite these encouraging results, the health risks associated with smoking remained a consideration. In response to the IOM’s call for nonsmoked, rapid-onset, safe, and effective cannabinoid delivery systems, we conducted a clinical trial to assess the Volcano®, a vaporization-based THC delivery device. Vapors are hypothesized to be less toxic than smoke and possibly more psychoactive, since less THC is burned off. The eighteen-participant, randomized, blind study compared plasma THC levels after using the Volcano® to those obtained after smoking an identical amount of equally potent marijuana (Abrams et al. 2006). Concentrations of expired carbon monoxide were measured as a marker of exposure to toxic combustion products. Patients’ tolerance and preference for vaporization versus smoking were also assessed. The Volcano® delivered similar peak amounts of THC over time as smoking. Vaporization produced significantly less carbon monoxide. Fourteen of the eighteen participants preferred vaporization to smoking.

in relief of pain and a more prolonged period of opioid sensitivity before a dose increase is required. This NIDA-funded trial will first evaluate the drug-to-drug interaction between the two classes. Using the vaporizer decreases some of the concerns regarding a “smoked” medicine. However, many challenges to conducting medical-marijuana research persist. For example, obtaining funding and getting results published may be more difficult. It took four years to get the first THC study funded, and the results were declined by multiple journals before the Annals of Internal Medicine reconsidered an earlier rejection and accepted the manuscript. Results from the neuropathy trial remain unpublished but are currently under serious consideration at a major medical journal. Since marijuana is a Schedule I substance, research studies must use material supplied by NIDA. Since NIDA cannabis is typically less potent than that obtained from cannabis buyers’ clubs, study results may not be fully representative of the potential therapeutic impacts. Using “street” marijuana in a study is not an option. These challenges are indicative of the deeply entrenched biases against medicinal marijuana that persist within the medical and political establishment, despite long-standing evidence of the drug’s safety and effectiveness. Larger studies, better publicized research results, and education of doctors and patients alike are critical to overcoming these biases. In the meantime, we will continue to conduct studies to provide evidence to inform the discussion.

“Despite the political movement against marijuana, there have been consistent calls for more research into the drug’s potential medicinal uses.”

Ongoing Challenges to Research Research on medicinal marijuana continues. Promising areas for further investigation include relief from spasticity associated with multiple sclerosis and neuropathic pain caused by cancer drugs. Our current study will evaluate the pharmacokinetic interaction between opioids and vaporized cannabis (Couey 2006). It is postulated that when opioids and cannabinoids are given together, there could be a synergistic effect

Dr. Donald Abrams is Chief of Hematology-Oncology at San Francisco General Hospital. This article is based on a presentation given by Dr. Abrams at a Community Forum, hosted by the Conant AIDS Foundation, in March 2006. A review of the entire presentation can be viewed at www.conantfoundation.org.

november 2006 San Francisco Medicine 17


Extraordinary Medicine

Pancreas Transplantation Cellular or the Whole Organ? Peter Stock, MD

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iabetes mellitus impacts more than 130 million people worldwide, and in the U.S. it has been reported that one of every eight health care dollars is directed to the treatment of diabetes and its secondary complications. The importance of tight control with intensive insulin therapy in preventing the development of the neuropathy, nephropathy, retinopathy, and cardiovascular disease was well documented in the Diabetes Control and Complication Trial (DCCT). Unfortunately, even tight control could not prevent the development of the secondary complications, and these severely impacted the quality of life and risk of life-threatening hypoglycemic events. Successful solid-organ pancreas transplantation has achieved insulin independence and stabilized the progression of many of the secondary complications of diabetes. Unfortunately, many of these complications have progressed too far by the time most health care providers feel that the risks of surgery and immunosuppressants are justified. However, the results of the surgical procedure have improved dramatically in the last five years, shifting the risk/benefit ratio in favor of pancreas transplantation. Nonetheless, it is clear that a number of patients cannot tolerate the rigors of the extensive surgical procedure. In addition, it is also evident that earlier intervention prior to the development of secondary complications will be facilitated by a less invasive approach. In these respects, islet transplantation has significant benefits over pancreas transplantation. With an increasing population of diabetic patients seeking beta-cell replacement, it is important that health care providers have a current knowledge of the risks and benefits associated with either cellular or solid-organ beta-cell

replacement. This information will be essential to help patients adequately gauge the risk/benefit ratio of either strategy. Both cellular (islet cell) and solidorgan pancreas transplantation have had increasing success in achieving insulin independence for many patients. Whether to pursue the more physiologically stressful solid-organ transplant or to choose islet-cell infusion is often a difficult choice. Obviously, the decision should be based on the current success rate for each procedure, as well as the ability of the recipients to tolerate the physiologic stress associated with these interventions. The success of solid-organ pancreas transplantation, as defined by insulin independence, has increased dramatically over the last several years. The better results are principally due to improved strategies in terms of preventing both the alloimmune and autoimmune responses against the transplanted organ. Current rejection rates following simultaneous pancreas/kidney transplants have decreased from more than 80 percent to less than 20 percent in the last five years. The immunosuppressive regimens employ a lymphocyte-depleting agent used at the time of transplant (induction therapy), followed by maintenance therapy with the calcineurin inhibitor (CI) tacrolimus and the antiproliferative agent mycophenolate mofetil (MMF). These strategies have permitted the elimination of the beta-cell toxic steroids from maintenance therapy. Using steroid-free regimens, the rejection rates of this previously very im-

18 San Francisco Medicine November 2006

munogenic transplant have been reported at less than 10 percent (Kaufman et al. 2002; Freise et al. 2002). This very low incidence of acute rejection of either the kidney or the pancreas has resulted in better long-term results. The three-year pancreas allograft survival reported by the International Pancreas Transplant Registry, as defined by insulin independence, approximates 80 percent for pancreases performed either simultaneously with a kidney transplant (SPK) or after a kidney transplant (PAK). Pancreas transplants performed in the preuremic Type I diabetic patient (PTA) historically have had poorer results. The reasons for these results in this group of patients as compared to SPK or PAK patients relate to both immunologic and technical complications. From a technical standpoint, the preuremic patient is more likely to clot off the pancreas, since the platelets function normally in this group as compared to the uremic transplant recipient. This technical hurdle has been overcome with the use of perioperative anticoagulation. The immunologic hurdles have been overcome with the better immunosuppressive regimens previously described. As a result, the outcomes following pancreas transplant alone in the preuremic recipient are now approximating the results following SPK and PAK. This has given many transplant centers the impetus to increase the frequency of pancreas transplant performed in the preuremic patient, which has the benefits of preventing not only the potentially life-threatening hypoglycemic

“It has been reported that one of every eight U.S. health care dollars is directed to the treatment of diabetes and its secondary complications.�

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episodes but also the development of the secondary complications of diabetes. Successful long-term function of solidorgan pancreas transplants as defined by insulin independence has normalized HgbA1C levels, prevented recurrent disease in simultaneous kidney transplants, stabilized retinopathy, and improved neuropathies (Fioretto et al. 1998; Navarro, Sutherland, and Kennedy 1997; Gross, Limwattananon, and Matthees 1998). However, it is also important to point out that only a small number of Type I diabetic patients can benefit from this procedure, as a result of both the cardiac stresses associated with solid-organ transplantation and the limited number of suitable deceased-donor pancreases available for transplantation. For this reason, islet transplantation remains an important alternative with the potential for more widespread application. Pancreatic islet transplantation provides a safer and less invasive alternative for beta-cell replacement as compared to solid-organ transplantation. In theory, this less invasive approach would permit betacell replacement at an earlier time in the course of diabetes to prevent its devastating complications. Unfortunately, until recently, the survival of the pancreatic islets following transplantation was poor compared to insulin independence observed following solid-organ transplantation. Recent advances in the technology of islet isolation as well as improvements in immunosuppressive strategies to prevent alloimmune and autoimmune destruction have stimulated increasing interest in this field. The intraportal infusion of islets is the only technique that has successfully produced insulin-independent states in humans. Following the isolation and culture of islets from a deceased-donor pancreas, the islets can be infused into the portal system of the liver using either percutaneous transhepatic cannulation or via branches of the mesenteric venous system cannulated by direct exposure using a minilaparotomy. Either strategy is significantly less stressful than solid-organ transplantation and requires a one- to two-day hospitalization. Despite multiple trials of islet transplantation as a treatment for Type I diabetes, it was not until 2000 that the group from the www.sfms.org

University of Alberta (Edmonton) reported that islet transplantation could consistently produce states of insulin independence (Shapiro, et al. 2000). This group made two significant changes from previous strategies, which appeared to account for its success. The first involved the use of multiple infusions of islets isolated from different donors in order to get enough islets (8,000 to 9,000 islet equivalents/kg) to create insulin independence. The second major difference involved the use of an immunosuppressive strategy that avoided agents that were known to be toxic to beta-cells. Steroids were eliminated from the regimens, and the levels of calcineurin inhibitors (tacrolimus) were minimized. Induction therapy with an IL-2 receptor inhibitor was used, and the nonbeta-cell toxic agent sirolimus was used to minimize the dose of tacrolimus. Using this strategy, insulin independence was achieved in more than 80 percent of recipients. Unfortunately, over the course of five years, fewer than 15 percent remained insulin independent (Shapiro et al. 2006). The loss of insulin independence has been attributed to rejection and lack of beta-cell regeneration/proliferation. In addition, islet transplantation has been more effective in patients with lower BMI and lower insulin requirements, consistent with the necessity for the transplantation of a larger beta-cell mass to achieve insulin independence. Interestingly, other islet transplant regimens that have used more aggressive induction therapy with lymphocyte-depleting agents have resulted in better long-term results than those achieved in the Edmonton trial. A recent report from the University of Minnesota/UCSF reported several patients who have enjoyed insulin independence for more than three years after receiving intraportal islets from a single donor. The regimen employed a lymphocyte-depleting agent (nonbinding humanized OKT3) at the time of the transplant (Hering et al. 2004). These findings would support the theory that the loss of islet function in the Edmonton trial can be attributed to insuf-

ficient immunosuppression, although lack of regeneration/proliferation could also be a contributory factor. In any case, while it is evident that islet transplantation has become a safe and effective procedure, expansion of this technology will require a better source of islets, as well as the continued development of nontoxic immunosuppressive regimens to prevent recurrent autoimmunity and alloimmunity. There is no question that the widespread application of islet transplantation will be greatly facilitated by further development of stem cell technology to create an unlimited source of beta-cells. Based on the current success of solidorgan pancreas transplantation and islet transplantation as a cure for Type I diabetes, an algorithm for the most appropriate form of beta-cell replacement can be proposed. Since the toxicities and risks of immunosuppressive therapy are associated with both islet and solid-organ transplantation, either procedure should be limited to preuremic patients with life-threatening diabetes or patients requiring immunosuppression for a transplanted kidney. For patients with adequate cardiac reserve, solid-organ transplantation continues to offer higher rates of long-term insulin independence. However, islet transplantation is a viable alternative for patients with advanced cardiovascular disease or patients who want to avoid the rigors of the surgical procedure. The chance of creating a state of insulin independence following islet transplantation is improved in patients with a low BMI or low insulin requirements as a result of the marginal beta-cell mass that is infused with a standard islet preparation. Significant advances in the field of islet transplantation with better immunosuppressive strategies are resulting in prolonged periods of insulin independence and are being tested in JDRFand NIH-sponsored protocols. Extensive application of cellular transplants will be accomplished with improved and less toxic immunosuppressive regimens, as well as the development of new and unlimited sources of beta-cells with stem cell technology.

“Both cellular and solid-organ pancreas transplantation have had increasing success in achieving insulin independence for many patients.�

november 2006 San Francisco Medicine 19


Extraordinary Medicine

The Art of Healing Q & A with Rachel Naomi Remen, MD Katie Kelly, Second-Year Medical Student, UCSF

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his month, San Francisco Medicine had the opportunity to interview Rachel Naomi Remen, MD, about the difference between curing and healing, and how physicians can heal patients with incurable diseases—an often extraordinary feat. Dr. Remen is one of the most respected pioneers of the mind-body health movement. Her unique perspective on healing comes from her background as a physician, professor of medicine, therapist, and a long-term survivor of chronic illness. She is director of the Institute for the Study of Health and Illness (ISHI) at Commonweal in Bolinas, California, and her course, The Healer’s Art, is taught in fifty-three medical schools nationwide. She has also cared for thousands of people with cancer through her private practice of psychooncology. Dr. Remen is currently a clinical professor at the University of California, San Francisco School of Medicine.

SFM: Many people think physicians see patients with the primary intention of improving their physical health. How does this compare to the goals or intentions in your patient relationships?

SFM: Would you expand on how a patient can be healed in the absence of a cure?

SFM: How does curing differ from healing? Remen: Basically, curing is about repair and healing is about growth. So curing is something we do to others, and healing something we evoke in others. Curing happens at the level of the body and leads to a renormalization of physiology. Healing happens at the level of the person and involves an evolution and refinement of the individual, a deepening of the capacity for emotional life, mental life, and spiritual life—the furthering of personal wholeness. Healing promotes the quality of life and the capacity to engage with life.

So there is a point when curing is considered complete, but healing is a lifelong process that we are involved with all of the time. It is possible for people to be cured and not heal, or to heal in the absence of definitive cure. Sometimes people recover physical integrity, but they do not heal emotionally or mentally or spiritually; they live their lives in fear of recurrence or in bitterness over their past losses. Others never recover their physical integrity but live with a greater passion and authenticity than before.

Remen: I am concerned with physical health as a prime outcome, but it is not the only outcome that concerns me, and not necessarily the only successful outcome of my relationship with a patient. I see physical health not as a goal but as a means. It allows people an opportunity to follow what has meaning and value in life. But one can do this whether one is physically healthy or not. After thirty years of caring for people with cancer, it seems to me that many people may begin to do this only after an experience of profound illness. The paradox here is that illness often initiates growth and healing.…

20 San Francisco Medicine November 2006

Remen: Yes, it is possible and even common to heal in the presence of disease, and even to die healed. Healing is less limited than curing. After years in medicine, most of us have discovered that we can heal with our humanity things that we cannot cure with our science. Curing is not always possible, but healing is a potential in all relationships and at all times. In the presence of chronic illness, and even because of it, people are often able to grow as persons in their capacity to love and feel compassion, in their sensitivity and understandings their courage and wisdom. Because of this capacity for growth, it is possible for people to lead a full life despite ongoing illness, to lead a meaningful life even though it is not an easy life or even a long life. SFM: Would you tell us what qualities or skills of a physician help their patients to heal? Remen: We heal with our presence. In order www.sfms.org


to help others to heal, we need to bring our wholeness into the examining room with us: our strengths, our courage, our caring, and even our anger and fears and doubts. This may give our patients permission to be genuine and whole as well and enable them to find the inner strength to deal with their issues and to grow from them. In the presence of another whole person, no one need be ashamed of their pain or their weakness—no one need feel alone. Everyone alive has suffered. It is the wisdom gained from our wounds and our own experiences of suffering that make us able to trust the process of healing and able to accompany other people as they heal. Wounded people are usually healed by other wounded people. Only other wounded people can understand what is needed, for the healing of suffering is compassion, not expertise. Becoming an expert has turned out to be less important in the long run than becoming genuine and remembering and trusting the hidden capacity for wholeness in myself and everyone else. It is hard to believe that we can heal others when we know we are wounded ourselves. But often our own wounds make us trustworthy and give us the wisdom and power to heal. Our wounds enable us to trust the healing process. Our hurts can move us beyond judgment and teach us compassion for the hurts of other people. Our loneliness enables us to recognize the hidden loneliness in others despite the masks that we all wear, and to find them when they are lost in the dark. It has been humbling to discover that often my medical expertise is not what makes the most difference to someone, but that they have been able to access their strength and transcend their suffering because of something I learned from my Russian grandmother or from my own fifty-three-year personal experience with Crohn's disease. SFM: So what are the tools one uses to heal? Do they differ from the tools one uses to cure disease? Remen: Yes, we cure with our expertise, but we heal with our life experience and our attention. We heal most often with our presence, and perhaps the most common www.sfms.org

tool of healing is just listening—not in the way we usually listen or the way in which many of us have been trained to listen. Most of us are thinking when we listen. Do we agree or disagree? Is what is being said accurate or not? Or we listen competitively: Is the speaker better educated than we are? Smarter or not as smart? More articulate or less articulate? We become very busy with all of these concerns. But this is not the sort of listening that heals others and enables them to hear the truth in themselves. When we heal, we abandon all such concerns and simply listen generously to someone—not in order to position ourselves or even to understand what is being said. We listen just to know what is true for this person at this moment in time—to witness it and validate it—and accept it. The paradox being that the things we accept as true about ourselves lose their hold on us and we begin to change. In order to heal my pain, I must accept that I am in pain—difficult as that is—and someone else must acknowledge that I am in pain. Then we can begin to make change. Listening is the oldest and perhaps the most powerful tool of healing. SFM: Are there other tools besides listening? Remen: Another healing tool is simple touch. In this culture, many people are afraid to touch others. I was trained that it is only permissible to touch people in order to diagnose them. We may need to find acceptable ways to touch more. Touch is deeply reassuring and nurturing and one of the oldest and perhaps most powerful tools of healing. There is considerable scientific evidence that touch may strengthen the will to live in people. Years ago, a groundbreaking study at the Karolinska Institute demonstrated that tiny premature infants carried in a little “kangaroo” pouch against their mothers’ skin had a higher survival rate that those kept in incubators surrounded by state-of-the-art technology. There may more to affecting a positive outcome than we at present understand. SFM: What is the task of those in medicine in the years to come?

Remen: One of the great challenges of our time is to make technology and science humanly relevant, not only in medicine but also generally in our culture: To become both healers as well as curers, and to lay claim to our full power to make a needed difference.

SFMS Night at the Symphony Seats are limited, and they’re going fast for the SFMS Night at the San Francisco Symphony on Thursday, November 30th! Enjoy a preconcert reception in the Davies Symphony Hall Green Room with hors d’oeuvres and beverages, followed by a vibrant program of Rachmaninoff and Tchaikovsky conducted by Vladimir Ashkenazy. Orchestra seats are $77.00, first tier are $67.00. The deadline to order tickets is Wednesday, November 8th! For more information, or to order tickets, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

SFMS Tennis Mixer The mixer will take place Thursday, January 18, 2007 at the San Francisco Tennis Club. This event will be a fun and relaxing introduction to the courts and amenities of this top-notch club, followed by a margarita mixer with light appetizers. More information available soon.

november 2006 San Francisco Medicine 21


Extraordinary Medicine

Revisiting Hallucinogen Research An Experimental Model with Advance-Stage Cancer Patients and Anxiety Charles S. Grob, MD

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fter a thirty-five-year hiatus, sanctioned clinical investigations of hallucinogens have resumed. Once on the cutting edge of psychiatric research, the cultural and political turmoil associated with their clandestine use led to extensive repression and neglect of hallucinogens as a novel treatment paradigm. Few contemporary practitioners recall the exciting advances made during the 1950s and 1960s in research that demonstrated promising rates of response to otherwise difficult-to-treat clinical conditions, including chronic alcoholism, drug addiction, obsessive-compulsive disorder, posttraumatic stress disorder, and the existential anxiety associated with end-stage medical illness. Whereas the effectiveness of conventional treatments for many of these conditions has often remained limited, efforts to carefully examine the relative risks and benefits of the hallucinogen treatment model have only been allowed to resume in the past few years (Grinspoon and Bakalar 1979; Grof 1980; Grob 1999; Grob 2002; Walsh and Grob 2005). To appreciate the full range of clinical application of the hallucinogen treatment model, including essential safety parameters, it is necessary to reexamine the accrued record from the previous generation of research. A particular area in which medical and psychiatric investigations revealed considerable promise was the highly structured and controlled administration of hallucinogens to dying patients suffering from profound psychospiritual demoralization. In spite of notable advances in the field over the last three decades, including the development of the hospice movement and the field of palliative care in providing greater and more humane attention to the treatment

of physical and emotional pain, it remains an unavoidable fact that innumerable individuals approaching the final phase of their lives experience terrible psychological anguish that often precludes a peaceful, tranquil, and dignified death (Rousseau 2000). This profound spiritual suffering shares many features of depression, including feelings of hopelessness, worthlessness, and meaninglessness. Indeed, depression

“Once on the cutting edge of psychiatric research, the cultural and political turmoil associated with their clandestine use led to extensive repression and neglect of hallucinogens as a novel treatment paradigm.” and hopelessness are associated with higher rates of suicide, suicidal ideation, desire for hastened death, and interest in physicianassisted suicide (Cochinov 2000, Breitbart et al. 2004). During the 1960s and early 1970s, investigators initiated research studies designed to explore the use of hallucinogens to treat the existential anxiety, despair, and isolation often associated with terminal cancer. Reports from that time were highly encouraging, describing critically ill individuals undergoing psychospiritual epiphanies, often with powerful and sustained improvement in mood and anxiety regulation, as well as diminished pain perception and need for narcotic medication. The first

22 San Francisco Medicine November 2006

investigator to methodically examine the effects of hallucinogens on pain perception in terminal cancer patients, University of Chicago internist Eric Kast, observed a significant reduction in the tenacity and intensity of physical pain without the mental dulling and awareness-constricting effects often observed with narcotic analgesia. Additional findings included relief of depression, improved sleep, and lessened fear of death. Kast suggested that his patients’ pain was controlled by a process he described as the “attenuation of anticipation,” a liberation from anxiety about loss of control during dying and death (Kast 1962, Kast and Collins 1964). Kast also found that the transcendent state of expanded consciousness often observed in patients undergoing a hallucinogenic experience enhanced their capacity to maintain interest in their lives and helped create “a new will to live and a zest for experience, which, against a background of dismal darkness and preoccupying fear, produces an exciting and promising outlook. In human terms, the short but profound impact upon the dying patient is impressive” (Kast 1966). A comprehensive program designed to explore the effects of hallucinogens on terminal cancer patients was conducted at the Maryland Psychiatric Research Institute from 1965 to the early 1970s, first under the leadership of Walter Pahnke and subsequently under Stanislav Grof. Pahnke, a Harvard-trained doctor of divinity and a psychiatrist, reported that the most dramatic effects came in the wake of mystical experiences, with two-thirds of his treated cancer patients demonstrating decreased “tension,” depression, pain, and fear of death. In the Harvard Theological Review, Pahnke described that he observed “an increase in www.sfms.org


serenity, peace, and calmness. Most striking was a decrease in the fear of death. It seems as if the mystical experience, by opening the patient to usually untapped ranges of human consciousness, can provide a sense of security that transcends even death. Once the patient is able to release all the psychic energy which has tied him to the fear of death and worry about the future, he seems able to live more meaningfully in the present. He can turn his attention to the things which have the most significance in the here and now. This change of attitude has an effect on all the people around him. The depth and intensity of interpersonal closeness can be increased so that honesty and courage emerge in a joint confrontation and acceptance of the total situation” (Pahnke 1969, p. 12). One of the final programs exploring the therapeutic potential of hallucinogens before clinical research was shut down was led by Stanislav Grof, a highly accomplished psychiatric investigator in Europe and the United States who worked from the 1950s to the early 1970s. Before his program was terminated by political pressure, Grof studied 60 terminal cancer patients using either LSD or DPT (dipropyltryptamine), of whom 29 percent improved dramatically and 41.9 percent improved moderately. Grof wrote that “probably the most surprising of the findings were the changes in the attitude toward death and in the concept of death itself. Increased acceptance of death usually followed sessions in which the patients reported deep religious and mystical experiences, whereas improvement of the emotional condition of the patients and relief of pain was frequently observed even after sessions with predominantly psychodynamic content” (Grof 1973, p. 143). The hallucinogen treatment model offers a remarkable opportunity to address the universal existential dilemma faced by the dying. Recent contributions to research by Roland Griffiths at Johns Hopkins demonstrate that psilocybin, administered under optimal conditions, may safely and reliably induce legitimate mystical experiences in normal volunteers, strengthening the case for the judicious use of hallucinogens with patients in profound psychospiritual crisis (Griffiths et al. 2006). Indeed, such treatwww.sfms.org

ment may be considered existential medicine designed to directly intervene and ameliorate the emotional and spiritual suffering of dying patients. Under the influence of hallucinogens, individuals transcend their primary identification with their bodies and experience ego-free states, and then return with a new perspective and profound acceptance of change, the constant in life. Experiencing oneself in a transitional state and with a new equilibrium and consciousness, identification with the dying body ceases. This implicit acceptance of the inevitable cycles of life leads to a greatly altered approach to the time remaining, enabling patients to experience it without the panic, fear, anger, pain, and dependency that were previously so overwhelming (Fisher 1970). Since 2004, research into the potential therapeutic efficacy of psilocybin in advanced-stage cancer patients with anxiety has been underway at Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute. Psilocybin, the active alkaloid in hallucinogenic mushrooms and a potent agonist of 5-HT(2A) and 5-HT(2C) receptors in the brain, was discovered in the 1950s by the legendary Swiss chemist Albert Hofmann and subjected to clinical psychiatric research investigation during the 1960s. Recently, it was the hallucinogen employed in the Johns Hopkins project studying mystical experience; and it was used in a University of Arizona pilot treatment investigation with patients suffering from severe, refractory obsessive-compulsive disorder (Moreno et al. 2006, in press). The Harbor-UCLA study is the first approved investigation in more than thirty years that explores the hallucinogen treatment model for the existential anxiety in advanced-stage cancer patients. Given the need to use stateof-the-art research methodologies, a doubleblind, placebo-controlled design has been employed, with each subject functioning as his or her own control. Prospective subjects are carefully screened and prepared for the experience, which is structured accord-

ing to the Pahnke-Grof model developed decades ago. The experimental sessions are conducted at the General Clinical Research Center at Harbor-UCLA Medical Center, where all treatments receive careful medical and psychological monitoring. Researchers follow up for six months after treatment with examinations of medical status, level of pain, anxiety, mood regulation, and overall quality of life. Further information, including inclusion-exclusion criteria and contact information, is available at www.canceranxietystudy.org. The study was developed and supported with funding from the Heffter Research Institute (www. heffter.org).

“The hallucinogen treatment model offers a remarkable opportunity to address the universal existential dilemma faced by the dying.”

Charles S. Grob, MD (pictured below with his daughter), is Director of the Division of Child and Adolescent Psychiatry at Harbor-UCLA Medical Center and Professor of Psychiatry and Pediatrics at the UCLA School of Medicine. He conducted the first U.S. government-approved psychobiological research study of MDMA, and he was the principal investigator of an international research project in the Brazilian Amazon studying ayahuasca, a visionary plant brew. He is currently conducting an approved research investigation into the safety and efficacy of psilocybin treatment in terminally ill patients with anxiety (www.canceranxietystudy.org). He is the editor of Hallucinogens: A Reader, published by Tarcher/Putnam in 2002, and the coeditor (with Roger Walsh) of Higher Wisdom: Eminent Elders Explore the Continuing Impact of Psychedelics, published by SUNY Press in 2005. He has published numerous articles on psychedelics in medical and psychiatric journals and collected volumes. He is a founding member of the Heffter Research Institute, which is devoted to fostering and funding research on psychedelics.

november 2006 San Francisco Medicine 23


Extraordinary Medicine

Teenager Refuses Treatment Can a Minor Legally Make the Choice to Refuse Lifesaving Chemotherapy? Stephen J. Askin, MD, and Rebecca L. Cachia-Riedl

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ust off the Atlantic coast of Virginia lies the small island of Chincoteague, protected from the ocean by the larger island of Assateague. Chincoteague has an oyster industry that produces some of the most delicious oysters in the Chesapeake Bay area. On this island lives sixteen-yearold Starchild Abraham Cherrix, with his parents, Rose and Jay Cherrix. In the summer of 2005, Abraham was diagnosed with Hodgkin’s disease and given a cycle of chemotherapy. The unpleasant symptoms associated with the treatment were so intolerable that he declined any further chemotherapy and began the Hoxsey method of treatment, which consists mostly of herbs and other supportive treatments—long discredited and banned in the United States, but available in Tijuana, Mexico. Abraham’s parents supported his decision. A social worker reported this case to a Virginia juvenile court, which considered it in the summer of 2006. A judge found the parents neglectful and ordered Abraham to report to a hospital for appropriate treatment, supposedly chemotherapy. At one point he was told that, if necessary, he would be taken to the hospital by law officers, strapped down, and given the treatment. This evoked an energetic reaction by Abraham and his family, who engaged a lawyer to appeal the decision, and there was considerable public comment. It should be pointed out that there is much we don’t know about the facts of this case; it was not possible to interview the Cherrix family, and the information regarding this case is based on articles from the San Francisco Chronicle and those reported by The Associated Press, as well as radio interviews on the “Sean Hannity Show.” Even without all the facts, this case poses

several ethical and legal dilemmas. What should the caregivers do when an intelligent and articulate teenager refuses lifesaving treatment? What is, and what should be, the status of an ineffective alternative treatment in our society when it allows a patient to decline a more effective treatment? What is the law in such a case? The frustrating factor in this case is that Hodgkins lymphoma, a life-threatening malignancy, responds well to chemotherapy, with or without radiation. I learned from a conversation with Leslie Moretti, MD, who is a Bay Area medical oncologist, that advanced Hodgkins has about a 70 percent cure rate, and that early Hodgkin’s has about a 90 percent cure rate. Dr. Moretti states that his patients have practically always been able to tolerate chemotherapy and don’t drop out of his treatment program. On the other hand, consider the Hoxsey method. This treatment was developed in 1840 by John Hoxsey. He observed one of his horses to have a tumorous growth, which went away as the horse ate various plants in the field where he grazed. Hoxsey collected the plants and used them to treat tumors in horses. The herbal formula was handed down from father to son until a Harry Hoxsey used it to treat human cancer patients from the 1920s through the late 1950s. At one point, he had ten thousand patients under his control in his Dallas clinic. He was then denied permission to practice his trade by the FDA, and the clinic closed. His cancer tonic contained potassium iodide, licorice, red clover, burdock root, stillingia

24 San Francisco Medicine November 2006

root, berberis root, poke root, cascara, prickly ash bark, and buckthorn bark. Most or all of these substances have been tested for anticancer properties (using animal models) by the National Cancer Institute and other organizations, and no anticancer activity has been found. Clinical evaluation of patients is difficult because of incomplete records, but no evidence of effective treatment against cancer in humans has been found. Since 1963, the Hoxsey treatment has been offered at a clinic in Tijuana, Mexico; for years it was run under the direction of Hoxsey’s chief nurse, Mildred Nelson, who is now deceased. The example of the Hoxsey treatment illustrates the harm an untested alternative treatment can do—in this case having no effect on the disease in question, while costing the patient untold amounts of money. By and large, the Hoxsey treatment is unproven, otherwise it would be mainstream. The FDA, as well as organized medicine and the U.S. Department of Health and Human Services, should take a more active role in evaluating questionable “drugs” and practices, as well as educating patients as to their effectiveness and safety. Teenagers do have some rights to make decisions concerning their health care. In this case, the two sides reached a consent decree that the judge approved. Abraham Cherrix will be treated by an oncologist of his choice who is board-certified in radiation therapy and interested in alternative treatments. Chemotherapy will not be required. He will be followed by the court until he is eighteen years old, and his parents will

“What should the caregivers do when this intelligent and articulate teenager refuses lifesaving treatment?”

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not be considered medically neglectful. As Abraham becomes older and wiser, he may want the most effective treatment. After all, consent to treatment can be an ongoing process, as the patient learns more about his disease. The following assesment, by Rebecca L. Cachia-Riedl of Hassard Bonnington, LLP, will clarify the legal issues that would have surrounded this case had it taken place in California. Minor’s Refusal of Lifesaving Medical Care In California, an adult has the legal right to refuse medical treatment of any kind, whether it is complex, simple, or life-sustaining. But what about minors like Abraham Cherrix, who are not legally considered competent to make their own decisions? Can these minors refuse lifesaving treatment? Most likely they can, if they understand the risks, benefits, and alternatives of the treatment, and understand the consequences of their refusal. There exists a strong public policy in California that gives patients the right to refuse medical treatment. This is codified in state statutes and regulations and has been upheld in state appellate court decisions. The California Constitution explicitly provides for the right of privacy, which encompasses the right to control decisions relating to a person’s own health care. This public policy is also the foundation for the doctrine of informed consent and its corollary, informed refusal. With respect to minors, the general rule is that a minor’s consent is delegated to parents or guardians with legal custody of the child. There are some special statutory circumstances in which the minor has the legal capacity to make health care decisions. While California does not explicitly give a minor the right to refuse lifesaving medical care, it does permit a child over the age of fourteen to object to surgical care. However, it also provides the child’s objection can be overridden by the courts when the child is not mature enough to appreciate the consequences of the refusal. Likewise, if the child’s parents or guardians cannot agree upon a recommended course of treatment, the courts can resolve the matter. If www.sfms.org

a child over the age of fourteen, or an even younger but articulate child, objects to nonsurgical treatment, the treating health care provider would be best advised to consult legal counsel before forcing treatment upon that child. In resolving whether or not medical care can be given to a minor where there exists an issue of refusal, or where the child is a ward of the court, the courts are asked to determine if such medical care would be in the child’s best interests. Depending upon the facts of any specific case, there may be additional or fewer relevant factors for the courts to consider; but in general, the factors to be considered are the following: • The child's present levels of physical, sensory, emotional, and cognitive functioning; • The quality of life, life expectancy, and prognosis for recovery with and without treatment, including the futility of continued treatment; • The various treatment options and the risks, side effects, and benefits of each; • The nature and degree of physical pain or suffering resulting from the medical condition; • Whether the medical treatment being provided is causing or may cause pain, suffering, or serious complications; • The pain or suffering to the child if the medical treatment is withdrawn; • Whether any particular treatment would be proportionate or disproportionate in terms of the benefits to be gained by the child versus the burdens caused to the child; • The likelihood that pain or suffering resulting from withholding or withdrawal of treatment could be avoided or minimized; • The degree of humiliation, dependence, and loss of dignity resulting from the condition and treatment; • The opinions of the family, the reasons behind those opinions, and the reasons why the family either has no opinion or cannot agree on a course of treatment; • The motivations of the family in advocating a particular course of treatment; • The child's preference, if it can be ascertained, for treatment; and • Whether the child appreciates and understands the risks and benefits of the

treatment and the consequences of the decision. Many may criticize the decision of sixteen-year-old Abraham Cherrix and his family to forgo lifesaving treatment for his Hodgkin’s disease, because the benefits of chemotherapy would outweigh the burdens of treatment in terms of a cure and a long life expectancy. However, California courts would look at the bigger picture and take the child’s and his family’s objections into account. Had Abraham’s case come through the California courts, it is likely he would have been permitted to refuse treatment because of his ability to appreciate and understand the risks, benefits, alternatives, and consequences of his decision—although it would always remain the job of his physicians to make sure adequate disclosures were made to him and his parents so they could continue to assess that decision.

November 29, 2006

Universal Health Care Access in San Francisco: Reality or Dream? California Pacific Medical Center 5:30 p.m.–7:70p.m. SFMS and CPMC’s Program in Health and Human Values will present a forum on the ongoing effort to provide access to health care for every San Franciscan. For information and to RSVP, contact Steve Heilig at the SFMS, (415) 561-0850 extension 270 or heilig@sfms.org.

January 28-30, 2007

UCSF-CHE Summit on Environmental Challenges to Reproductive Health and Fertility Mission Bay Conference Center, UCSF, San Francsico. This summit will provide overviews by leading researchers of science and environmental contaminant impacts on reproductive health and fertility. Contact Mary Wade for more information, (415) 476-2563 or wadem@obgyn.ucsf.edu.

november 2006 San Francisco Medicine 25


Extraordinary Medicine

The Healing Power of Sound The astonishing results of sound upon blood, water, cancer cells, and neurons Simon Heather, MBACC, MCOH

S

ound has been used as a healing force for thousands of years. All ancient civilizations used sound for healing. Traditional cultures still surviving today understand the remarkable healing power that lies in sound. In the Bible we are told that David played his harp to lift King Saul’s depression. Egyptian papyri more than 2,600 years old refer to incantations as cures for infertility and rheumatic pain. The ancient Greeks believed music had the power to heal body and soul. They used the flute and the lyre for treating illnesses such as gout and sciatica. It is reported that Alexander the Great’s sanity was restored by music played on the lyre. There is an ancient Greek saying, “Men have song as a physician for pain.” Pythagoras used special songs and incantations with particular melodies and rhythms to cure diseases of the body and mind. What Is Sound Healing?  Sound healing is the therapeutic application of sound frequencies to the body/mind of a person with the intention of bringing them into a state of harmony and health. The dictionary defines harmony as “congruity of parts to their whole or to one another.” Health is defined as “the state of being bodily and mentally vigorous and free of disease.” The French ear, nose, and throat specialist Dr. Alfred Tomatis has devoted the last fifty years to understanding the ear and its function. He believes that the ear is the most important of all our sense organs. The ear controls the body’s sense of balance, rhythm, and movement and is the conductor of the entire nervous system. Through

the medulla, the auditory nerve connects with all the muscles of the body. Hence muscle tone, equilibrium, flexibility, and vision are affected by sound. Through the vagus nerve, the inner ear connects with the larynx, heart, lungs, stomach, liver, bladder, kidneys, small intestine, and large intestine. Tomatis believes that high-frequency sounds (3,000 Hz and above) activate the brain and affect cognitive functions such as thinking, spatial perception, and memory. Listening to these sounds increases our attentiveness and concentration (Tomatis 1991). Resonance When an opera singer vibrates a glass with her voice, she has matched the resonant frequency of the glass. As the singer increases the volume of sound, the resonance becomes too great for the forces that hold the glass together and it shatters. Modern medicine now uses sound waves to break up kidney stones and gallstones. Every organ, every bone, every cell in the body has its own resonant frequency. Together they make up a composite frequency, like the instruments of an orchestra. When one organ in the body is out of tune, it will affect the whole body. The principle of entrainment states that powerful rhythmic vibrations from one source will cause the less powerful vibrations of another source to lock into the vibration of the first source. Nature always seeks the most efficient state; it takes less energy to pulse in cooperation than in opposition (Goldman 1992). Scientific Research into Sound Fabien Maman In 1974, Fabien Maman was working as a professional jazz musician. He noticed that certain musical keys had an energizing effect

26 San Francisco Medicine November 2006

on both the musicians and the audience. Fabien worked with the French physicist Joel Sternheimer, who had discovered that elementary particles vibrate at frequencies in accordance with musical laws. They found that body tissue, organs, and acupuncture meridians each have a musical note. A few years later, Fabien met Hélène Grimal, a senior researcher at the National Centre for Scientific Research in Paris. They devoted a year and a half to the study of the effects of sound on normal and malignant cells. Using drums, gongs, flutes, guitar, bass, and a xylophone, they investigated the effects of sound on healthy blood cells, hemoglobin, and the HeLa cancer cell. They found that even at thirty to forty decibels, the sound always produced noticeable changes in the cells. As the sounds progressed up the musical scale, there would be an “explosion” of the cancer cells at a certain frequency as the sound traveled outward from the center of the cell to its outer membrane. The experiment yielded the most dramatic results when the human voice was used. Fabien writes, “Near the end of the scale, usually around the seventh interval, the cancer cells exploded. It appears that the cancer cells were not able to support a progressive accumulation of frequencies…. The healthy cells appeared supple and able to freely receive, absorb, and return the energy. In contrast, the cancer cells appeared inflexible and immutable in their structure” (Maman 1997). In experimental sessions on actual cancer patients, the music produced equally astonishing results. Female volunteers with breast cancer were taught to tone the whole scale, using a violin to keep a base note for twenty-one minutes at a time. They spent www.sfms.org


three and a half hours a day doing this for a month. One woman’s tumor disappeared completely (Cambell 1997). Fabien Maman took healthy blood cells and played a xylophone to them. He photographed the changes in the electromagnetic fields around the cells using Kirlian photography. Subjected to a chromatic scale of frequencies, the slight difference of a half tone would produce a completely different shape and color in the energy field of the cell. He found that the C note made them longer, D produced a variety of colors, E made them spherical, and A (440 Hz) changed the color of the energy field from red to pink. In his next experiment, Fabien took a sample of blood from a person’s finger. He then asked the person to sing the seven notes of the major scale to their own blood cell. With each note, the cell’s energy field changed its shape and color. When the person sang an F to their own blood cells, the cells resonated perfectly with the voice, producing a balanced, round shape and vibrant colors of magenta and turquoise. Fabien says, “The cells are completely bathed in light and alive with full resonance, clear evidence that this F is the fundamental sound of the singer.… Fundamental sound can be very helpful for the physical body through its harmonizing and regenerating effect at the cellular level.” From his experiments, Fabien concluded “In the human voice there is an added element which cannot be found in any other instrument.… The human voice carries its own spiritual resonance.… This difference, evident from the photographs, is what makes the voice the most powerful healing instrument—particularly when the person needing the healing produced the sounds with his or her own voice.”      Jim Oliver says that the body responds to sounds that we cannot hear. He says, “We put the selected sounds exclusively into a pair of headphones and put them on a client’s ankles. They responded to the sound even though their ears could not hear the sound. Once you vibrate a part of the body, the blood cells carry this resonance to the whole body very quickly” (Oliver 1995). Masaru Emoto A Japanese scientist, Masaru Emoto, www.sfms.org

wanted to find a way of scientifically evaluating water quality. He decided to freeze samples of water taken from different sources to compare their crystalline structure. When pure water crystallizes, it forms a pure crystal; would contaminated water also form a pure crystal? He placed water in petri dishes in a freezer for two hours, then placed them under a microscope and photographed them at a magnification of two hundred to five hundred times. Although the crystals that formed were all unique, the crystals from water of the same source were all similar in shape. Over a four-year period, his team took ten thousand photographs. Tap water from Japanese cities generally would not form complete crystals. Tap water from London formed no crystals at all. Spring water generally produced the most beautiful crystals, as did water from holy places such as Lourdes. Masaru Emoto’s next experiment was playing music to water. He placed distilled water between two speakers and played one piece of music fully at normal volume. Then he froze the water. Classical music produced beautiful crystals of slightly different colors (pictured upper right). Healing music, a Tibetan mantra, and folk music also produced beautiful crystals. Heavy metal music produced a pattern that looked like a crystal that had exploded into a thousand pieces (pictured lower right). Japanese pop music produced ugly, square-shaped crystals rather then the normal hexagonal ones (Emoto 1999). Since our body is made up of 70 percent water, Masaru Emoto’s work demonstrates that we are constantly being influenced by the sounds around us. Music as Medicine Don Campbell, in his book The Mozart Effect, shows how music, particularly Mozart’s, has all kinds of beneficial effects for human health. Scientists suggest that listening to Mozart helps us improve our powers of concentration and enhances our ability to make intuitive leaps by organiz-

ing the firing pattern of neurons in the cerebral cortex. The fetus prefers Mozart and Vivaldi to other composers. When pregnant mothers listened to Mozart and Vivaldi, the babies’ heart rates invariably steadied and kicking declined. Rock music “drove most fetuses to distraction” and they “kicked violently” when it was played to their pregnant mothers. Slower-tempo music slows our breathing rate. The human heartbeat will tend to match the rhythm of music. Listening to Pachelbel’s Canon, for instance, at around sixty-four beats per minute, the rate of a resting heartbeat, will slow our breathing rate and heart rate and change our brainwave pattern from beta to alpha. Music will also calm our nervous system and affect metabolism. The pitch and rhythm of music influence the limbic system, affecting our emotions. Scientists concluded that preferred music “may elicit a profound positive emotional experience that can trigger the release of hormones, which can contribute to a lessening of those factors which enhance the disease process” (Harvey 1991). Music is now used to reduce the pain and anxiety of patients undergoing dental treatment and surgical operations. In a study of 59,000 patients, 97 percent stated that music really helped them to relax in the postoperative situation and during surgery in regional anesthesia. In his research, Dr. Mike Lewis found that classical music works on the whole brain, whereas pop music affects only one side of the brain. He says, “I recommend that those who are looking for a peak experience try classical. Mozart is a great place to start, but it is a question of trial and error; find what works for you” (Lewis 2000).

Editor’s Note: This article was reprinted with permission. It was originally published in Positive Health, Issue 64, May 2001, www. positivehealth.com.

november 2006 San Francisco Medicine 27


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Brachytherapy: Continued from page 15... two TRUS-guided HDR prostate implants, separated by a oneweek break. The morbidity of the treatment was low, with three patients developing grade 3 urinary toxicity. This is a remarkable result in a group of patients that had been previously irradiated. There has been a noteworthy resurgence of interest in prostate brachytherapy. Much of this interest grows out of the knowledge that improved delivery accuracy is made possible by advancements in technology. Many excellent clinical results have been reported by institutions using brachytherapy as the primary treatment, as a boost in treatment, or even as salvage treatment. As we can see from the history of oncologic therapy, brachytherapy has been an important part of radiotherapy, and it will no doubt continue to play an important role in the management of prostate cancer. It is an exciting time for physicians who are involved in brachytherapy, as new technologies are constantly being developed to improve the quality and results of the treatment. The authors collaborate in the Prostate Cancer Brachytherapy Service at the University of California and the San Francisco Comprehensive Cancer Center, Mt. Zion Hospital, San Francisco. Mack Roach III, MD, is a professor of Radiation Oncology and Urology; I-Chow Hsu, MD, is an associate clinical professor of Radiation Oncology; Alex Gottschalk, MD, PhD, is an assistant clinical professor if Radiation Oncology; Joyce Speight, MD, PhD, is an assistant clinical professor of Radiation Oncology; and Katsuto Shinohara, MD, is an associate professor of Urology and Radiation Oncology.

november 2006 San Francisco Medicine 30


hospital News Chinese

Fred Hom, MD

Congratulations to Dr. Irwin Chow for being named the new Chief of Anesthesia. Irwin “grew up” with Chinese Hospital, first as a student-volunteer, then as a medical staff office assistant, and now as a section chief. His mom is Ms. Karen Chow, a longtime Chinese Hospital employee who started as a nursing office secretary and worked up the ladder to become the Director of Human Resources. Thanks go to Dr. Frances Tse, who served as Chief of Anesthesia from 1988 until this year and who held the post in addition to his six years as chief of the medical staff. More congratulations go to the hospital’s entry into the International Dragon Boat Festival. The Health Dragons captured the Health Care Challenge Cup, defeating several other Bay Area Hospital teams in the process. Captain Seck Chan, MD, was joined by physician teammates Randall Low, Edward Chan, Arthur Chin, and Vernon Fong. Hospital employees included Elena Wong, Simmy Lee, Jiong Jiang, Sabrina Wong, Jennifer Hong, Alan Fernandez, Stuart Fong, Francis Lau, Hong Liang, Alice Louie, and Tiffany Chew.

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St. Mary’s

Saint Francis

Kenneth Mills, MD

Guido Gores, MD

At Saint Francis Memorial Hospital, we’ve had an extraordinary month with the opening of our state-of-the-art Emergency Department. The biggER, bettER, fastER ER expanded to nineteen patient beds in more than ten thousand square feet. The $12.6 million renovation took only eighteen months and completed the first phase of meeting California Seismic Safety Act standards. Our team of board-certified physicians and physician assistants, under the medical direction of California Emergency Physician Dr. Phillip Piccinini, are able to see patients within, on average, thirty minutes of arrival. The turnaround time from arrival to discharge is two hours; from arrival to hospital admission into a private room is four hours. Now, with greater space and more beds, we’ll serve nearly double the number of ER patients. The ER features the latest in technology, allowing for “extraordinary healing” in many areas. At every bedside, there are monitors and electrocardiograms that interface with clinical records, bedside dual-handset phones with direct access to certified medical translators, and flat-screen TVs. The new electronic clinical information system goes live on November 7 with bedside registration and both hardwire and wireless technology. The supply inventory system and pharmaceuticals are fully automated. Specialized rooms allow patients to receive care tailored to their specific needs, from OB/ GYN to pediatrics. Of the nineteen rooms, nine are private. Patients suffering from migraines and other conditions can find peaceful care in the designated “quiet room.” Two “safe rooms,” with unbreakable glass and other safety features, facilitate the care of patients who are a harm risk to themselves or others. Two negative-pressure rooms provide a safe environment for patients and staff. There is also a decontamination room with external access so that patients can be “deconned” before entering the ER. We welcome you to stop by for a visit, or arrange a tour.

When we see a patient who is ill and suffering, and we apply the principles and practice of medicine and the patient gets better, that is ordinary healing. When we see that same patient; see how he relates to family and community; apply the same principles and practice of medicine; and tend to his spiritual, emotional, and social needs, that is extraordinary healing. At St. Mary’s Medical Center, the religious and ethical directives remind us of the dignity of both the individual and the broader community.  The medical center and the medical staff have an organizational commitment to this extraordinary healing. Brother George Cherrie, Vice President of Mission and Community Services, leads the charge. We dedicate our resources to delivering compassionate, high-quality, affordable health services; serving and advocating for our sisters and brothers who are poor and disenfranchised; and partnering with others in the community to improve the quality of life. Each year, we develop a community benefit plan with input from the medical staff, board, and administration to focus on our priorities for community service.  Our clinic provided more than 36,000 visits in the past year, many of which represented free care. Of our registered patients, 1,700 have no health coverage. We have partnered with San Francisco General Hospital, Baker Places, Delancey Street, New Leaf, Haight Ashbury Services Association, and Walden House, just to name a few. We are hoping that St. Mary’s will be a notable presence in the new universal health access program here in San Francisco. Our outreach screening programs look at blood pressure, cholesterol, bone density, and diabetes. We support the Adult Day Health program and senior dining. Our HIV Clinic serves many in the Haight and Golden Gate Park. Newer and more innovative technologies are extraordinary, but so are people and organizations!

november 2006 San Francisco Medicine 31


hospital News St. Luke’s

Jerome Franz, MD

On September 19, a dinner and lecture was held at the hospital to promote more extensive screening for colorectal cancer. Our CEO, Martin Brotman, gave the overview and introduction, and Dr. Robert Elsen presented ways of motivating our patients (and our doctors) to screen regularly for the disease. This was the first of a planned evening series of programs for the medical staff. A permanent chief administrative officer has started working with Brian Goodell, who has been our interim CAO for the past year. Judy Li, most recently Director of Program Development at CPMC, will take on his role. Dr. Goodell, an internist and oncologist, has been highly respected by the doctors and staff at St. Luke’s for his ability to work with people and for his dedication to the renewal of our hospital. He will return to his home in Seattle and continue to work for Navigant. Ms. Li has already been very involved with St. Luke’s in the development of the Skirball Center, renamed Health First, which I described last month as our new model of comprehensive health care. We welcome her new appointment and look forward to working with her.

Seton

Julius Zsigmond, MD

Every Thursday at Seton Medical Center, doctors discuss case reports, review imaging studies, and recommend treatment options for oncologic patients at the Tumor Board forum. Not infrequently, patients anxiously await the recommendations of the multidisciplinary group of specialists. They hope that their disease can be cured with new drugs and treatment options. During our discussions, medical oncologists often recommend new drugs and drug combinations to treat advanced malignant disease. Some of these drugs are marketed and sold at exorbitant prices by the pharmaceutical companies. Just a few days ago, I read an article about Abraxane, a new version of Taxol, which is a drug used frequently in the treatment of advanced cancer. This new version costs $4,200 a dose; the justification for this price is that it is based on nanoparticle technology. This drug does not prolong life and boasts very little advantage over the old drug (although it may have slightly fewer side effects). It does not represent a breakthrough in cancer research, but it may provide new hope for a patient who thinks that this new drug will be more efficacious than the old one. However, it costs twenty-five times as much as the generic equivalent of Taxol. We physicians and surgeons are under constant pressure to provide our services at deeply discounted prices. No such pressure seems to apply to pharmaceutical companies. Should we, the medical community, voice our objections about these questionable pricing practices? Should one dose of a nanotechnology-based drug, which provides hope only for a few patients, cost eight times as much as the usual reimbursement for a hernia repair? Nanotechnology certainly can help humankind in the future, but only if the technical progress does not lead to the exploitation and decline of our health care system.

UCSF

Ronald Miller, MD

UCSF Medical Center is the first institution in California to acquire the Niobe magnetic navigation system by Stereotaxis, Inc. Physicians are now using the interventional robotic guidance system to perform remote interventional cardiac procedures, such as ablations to cure arrhythmias. The new computer-controlled equipment uses magnets to steer interventional instruments, such as catheters and guide wires, through veins into the heart and coronary arteries. Physicians digitally control movement of the instruments from a control room outside the operating suite, using monitors and point-and-click navigation tools and other instruments. “The system allows for 3-D mapping that is quicker and more accurate than previous systems, allowing us to correct complex arrhythmias with more precision and fewer complications,” said Jeffrey Olgin, MD, Chief of Electrophysiology at UCSF Medical Center. The magnets are able to move interventional devices in very precise movements, as little as one millimeter at a time, and 360 degrees in any direction. Some of the advantages of using magnetic navigation include increased flexibility of the interventional device (it can make ninetydegree or sharper turns to navigate small and difficult-to-access locations), a greater degree of speed and physician control (reducing procedure time), a reduced risk of perforation, and a reduction in radiation exposure for both patient and physician. For more information or to refer a patient, please contact the UCSF Cardiac Electrophysiology and Arrhythmia Service at (415) 476-8237.

Berenson, Alex, “Hope, at $4,200 a Dose,” The New York Times (October 1, 2006). 32 San Francisco Medicine November 2006

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Two recent studies led by Rebecca Sudore, MD, a staff physician at SFVAMC, shed new light on the potential link between literacy and health. A study in the August 2006 issue of the Journal of General Internal Medicine found that literacy at less than a ninth-grade level almost doubles the five-year risk of mortality among elderly people, regardless of education, socioeconomic status, or health. “From a public health standpoint, this has important implications,” said Dr. Sudore. “This is yet one more reason why improving the educational system in the U.S. is so important.” In another study led by Dr. Sudore that appeared in the same issue, only twenty-eight percent of adults understood a highly simplified medical consent form the first time they encountered it, even though the form was written at a sixth-grade reading level and read aloud to them in their native languages as they read it for themselves. “We cannot make the assumption that anyone, even highly literate native English-speakers, will understand medical consent information,” concluded Dr. Sudore. The Center for HIV Information, directed by SFVAMC Chief of Medicine Paul Volberding, MD, has released a free CD-ROM containing more than forty selected chapters from the HIV InSite Knowledge Base, an online resource that is widely respected as one of the most authoritative sources of HIV information in the world. “We have chosen the chapters that are most broadly applicable to HIV care in a variety of settings around the world, including those with limited resources,” said Dr. Volberding. “This will be a powerful tool for clinicians, particularly in the developing world, where Internet service is slow, unreliable, or unavailable.”

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november 2006 San Francisco Medicine 33


in memoriam Nancy Thomson, MD, SFM Obituarist

John B. Auerbach, MD John B. Auerbach, MD, a longtime urological surgeon, passed away on Memorial Day, May 29, 2006, at the age of 82. He was born on August 5, 1922, in Vienna, Austria. He moved to St. Gallen, Switzerland, as a child, where he lived until he could emigrate to the United States at the beginning of World War II. He served in the Merchant Marine during the entire period of armed conflict, rising from seaman to ensign by the time of his discharge from the U.S. Coast Guard in 1945. Dr. Auerbach attended Dartmouth College in New Hampshire and was awarded his MD degree from George Washington University Medical School in 1956. He served a surgical residency at Stanford University School of Medicine and, upon completing his training in 1959, became chief resident in Urology at the University of Oregon. He was certified by the American Board of Urology, was a fellow of the American College of Surgeons, and had been a member of the San Francisco Medical Society since 1958. He retired from medicine in 1988 to enjoy his passions: chamber music, Renaissance art, and wine grape growing. Dr. Auerbach is survived by his wife of 28 years, Barbara J.R. Jones.

Amos H. Lieberman, MD Amos H. Lieberman, MD, passed away at the age of 80 in San Francisco on June 13, 2006. He was born in New York City on August 28, 1925, to David and Mariam (Horowitz) Lieberman. Dr. Lieberman attended Columbia University, received his MD from Washington University in St. Louis, and completed his internship at Mt. Sinai. He served in the U.S. Army in Europe from 1944 to 1946, receiving a Bronze Star and a Purple Heart. He completed a residency in nephrology at Duke University School of Medicine in 1953. He did endocrinology research at Stanford University School of Medicine and joined the staff of Kaiser Permanente in San Francisco in 1958, serving as a nephrologist until he retired in 1974. He was also a clinical professor at UCSF. He joined the San Francisco Medical Society in 1960 and was also a member of the

CMA, AMA, and the American Society of Nephrology. He enjoyed tennis, travel, and reading history, especially about the Civil War. His wife, Elaine, predeceased him. He is survived by his two sons, Jeremy and Jonathan, both of whom are physicians—Jeremy at UCSF and Jonathan at Kaiser, San Francisco—and by two grandsons.  

Selby Mohr, MD Selby Mohr, MD, a dedicated ophthalmologist, died peacefully on August 31, 2006, surrounded by his family at his home in Seacliff, California. He was 88 years old.       Dr. Mohr was born in San Francisco on March 11, 1918, and graduated from Lowell High School in 1934, Stanford University in 1938, and Stanford University School of Medicine in 1942. He volunteered for the service in 1943, serving in the Navy Medical Corps during World War II.. After his Navy service, he opened his private ophthalmology practice at the Sutter Medical Building in San Francisco, where he practiced for 47 years. He was an ophthalmologic surgeon at Marshall Hale Memorial Hospital, where he served as chief of staff. He was a diplomat on the American Board of Ophthalomology, a member of the San Francisco Medical Society since 1943, and a member of the California Medical Association, the AMA, the Pan Pacific Surgical Society, and the Pan-American Society of Ophthalmology. Dr. Mohr was an avid adventurer and passionate gastronome who loved nothing better than traveling to the four corners of the world with his wife and children. He also was a lifelong duck hunter who treasured his weekends at the Duck Shack with family and friends.    He is survived by his wife of fifty-six years, Marian Buckley Mohr; sons Selby Mohr II, John Mohr, and Gregory Mohr; daughter Adrienne Vincent; and four granddaughters and two grandsons.  

Save the Date! 2007 SFMS Annual Dinner January 25 More information to follow 34 San Francisco Medicine november 2006

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